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RC76  .C81  1 896       Essentials  of  physic 


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ESSENTIALS 

OF 

HYSICAL   DIAGNOSIS 


THORAX. 


CORWiN. 


■^i'^'m 


Columbia  Winti^tviitv  ^^^& 
in  tfje  Cttp  of  Jgetu  gorb 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


ESSENTIALS 


PHYSICAL  DIAGNOSIS 


OF   THE 


THORAX. 


BY 

ARTHUR  M.  CORWIN,  AM,  M.  D, 

Demonstratob  of  Physical  Diagnosis  in  Rush  Medical  College; 

Attending  Physician  to  the  Centbal  Free  Dispensary, 

Department  of  Rhinology,  Laryngology, 

AND  Diseases  of  the  Chest. 


SECOND  EDITION,  REVISED  AND  ENLARGED. 


PHILADELPHIA : 
W.    B.    SAUNDERS, 

925  Walnut  Street. 
1896. 


Copyright,  1896, 
By  W.  B.  SAUNDERf 


ELECTROTYPED    BY  PRESS   OF 

WESTOOTT   8i   THOMSON,  PHILAOA.  W,   B.  SAUNDERS.   PHILADA. 


PREFACE  TO  THE  SECOND  EDITION. 


The  first  edition  of  this  book,  published  under  the  title 
"  Outline  of  Physical  Diagnosis  of  the  Thorax,"  was  chiefly 
intended  to  meet  the  immediate  wants  of  my  classes.  From 
its  rapid  distribution  it  has  seemed  to  have  reached  a  wider 
field.  The  present  edition  under  the  new  title,  as  published 
by  Mr.  Saunders,  is  a  revision  of  the  original  text,  with  an 
added  section  setting  forth  the  signs  found  in  each  disease 
of  the  chest. 

In  the  preparation  of  this  synopsis  I  have  availed  myself 
of  the  works  of  the  best  writers  upon  Diagnosis,  General 
Medicine,  Physiology,  and  Anatomy,  from  which  I  have 
endeavored  to  cull  the  essentials  of  the  subject  in  hand. 

To  Drs.  Wm.  R.  Parkes  and  John  Edwin  Ehodes  I  desire 
to  express  my  thanks  for  their  valued  services  rendered  in 
the  reading  of  the  proof. 

A.  M.  C. 


PREFACE  TO  THE  FIRST  EDITION. 


The  following  outline  aims  to  present  in  systematic  form 
the  gist  of  the  science  of  physical  diagnosis  as  applied  to  the 
thorax. 

In  this  form  it  is  hoped  that  the  salient  points  of  the  sub- 
ject may  be  the  more  readily  grasped  by  those  who  are  all 
too  busy,  while  in  medical  college,  to  seek  them  out  of  ex- 
tensive treatises  and  to  arrange  them  for  proper  assimilation. 

It  is  designed  to  meet  the  immediate  demands  of  the 
student,  and  to  be  a  further  guide  to  a  more  elaborate  study 
of  the  theme  as  set  forth  in  existing  literature,  and  as  fur- 
nished in  the  clinical  material  of  public  and  private  practice. 

While  the  intention  has  been  to  confine  the  subject  to  the 
thorax,  reference  has  been  made  to  some  of  the  abdominal 
organs,  and  to  various  phenomena  of  the  circulatory  system 
outside  of  the  chest,  where  these  have  seemed  to  be  specially 
related  to  the  chest  cavity  and  its  organs. 

I  am  indebted  to  Drs.  John  M.  Dodson,  James  B.  Her- 
rick,  John  Edwin  Rhodes,  and  George  H.  Weaver  for  sug- 
gestions in  the  correction  of  proof. 

A.  M.  C. 


Fig.  1.— Corwin's  Double  Binaural  Stethoscope. 


Fig.  2.— Corwin's  Multiplex  Stethoscope. 


Fig.  3.— Folded  Single  Stethoscope. 


THE 


PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 


THE 

PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 


Definition. — Physical  Diagnosis  is  the  science  and  art  of 
objective  examination  of  the  body  as  practised  upon  its 
surface. 

The  science  of  physical  diagnosis  deals  with  the  character, 
causes,  and  significance  of  physical  signs,  and  the  methods 
of  eliciting  them.  Signs  are  objective  features,  as  distin- 
guished from  symptoms,  which  are  purely  subjective. 

The  art  of  physical  diagnosis  is  the  practical  applica- 
tion of  the  science.  Its  aim  is,  therefore,  to  distinguish  ob- 
jectively between  health  and  disease,  and  between  various 
diseases. 

Introductory  Note. — Objective  examination,  though  deal- 
ing in  a  broad  way  with  the  entire  body,  finds  its  most  profit- 
able application  to  the  thorax,  which  is  therefore  the  field  of 
its  operation  as  considered  in  the  following  synopsis.  The 
four  divisions  of  the  subject  are  (1)  Topography  of  the  Chest ; 
(2)  Landmarks  of  the  Chest ;  (3)  Methods  of  Physical  Diag- 
nosis ;  (4)  Physical  Signs  common  in  and  peculiar  to  each 
Disease  of  the  Chest. 


17 


18  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

TOPOGRAPHY  OF   THE   CHEST. 

The  topography  of  the  chest  deals  with  the  regions,  their 
boundaries  and  their  contents. 


Fig.  4.— Anterior  surface  of  the  chest. 

ANTERIOE  EEGIONS. 

SUPRA-CLAVICULAR  regions. 
Boundaries : 

ABOVE,  the  line  drawn  from  the  junction  of  the  ex- 
ternal with  the  middle  third  of  the  clavicle  to  a  point 
at  the  inner  margin  of  the  sterno-mastoid  muscle,  on 
a  level  with  the  upper  ring  of  the  trachea. 
BELOW,  \)l\q  superior  border  of  the  inner  two-thirds 

of  the  clavicle. 
IWTERNALLY,   the   anterior   border   of   tlie  sterno- 
cleido-mastoid  muscle. 
Contents :  the  apices  of  the  lungs ;   parts  of  the  sub- 


TOrOUHArUY    OF   THE  VlUuST.  19 

clavian  and  carotid  arteries  ;  and   the   sulx.'lavian  and 
jugular  veins,  on  either  side. 

CLAVICULAR  regions. 

Boundaries  :  the  margins  of  the  inner  two-thirds  of  the 

clavicle. 
Contents : 

BIGHT  SIDE,  the  apex  of  the  lung. 
EXTERNALLY,  the  subclavian  artery. 
INTERNALLY,  the  innominate  artery  and  recurrent 
laryngeal  nerve. 
LEFT  SIDE,  the  apex  of  the  lung. 

EXTERNALLY,  parts  of  the  subclavian  vessels. 
INTERNALLY,  parts  of  the   subclavian  and  carotid 
vessels. 

INFRA-CLAVICULAR  regions. 
Boundaries : 

ABOVE,  the  lower  border  of  the  clavicle. 

BELOW,  the  lower  border  of  the  third  rib. 

INTEBNALLY,  the  border  of  the  sternum. 

EXTEBNALLY,  a  line  let  fall  from  the  junction  of 
the  middle  with  the  outer  third  of  the  clavicle,  and 
passing  down  an  inch  to  the  outer  side  of  the  nipple 
(some  authorities  give  the  mammillary  line). 
Contents : 

EITHEB  SIDE,  lung  tissue. 

BIGHT  SIDE,  a  part  of  the  aorta,  descending  vena 
cava,  and  right  bronchus. 

LEFT  SIDE,  the  pulmonary  artery  and  left  bronchus, 
the  base  of  the  heart  and  great  vessels. 

MAMMARY  regions. 
Boundaries : 

ABOVE,  the  lower  border  of  the  third  rib. 
BELOW,  the  lower  border  of  the  sixth  rib. 
INTEBNALLY,  the  margin  of  the  sternum. 
EXTEBNALLY,  a  line  let  fall  from  the  junction  of 


20  PHYSICAL  DIAGNOSIS  OF  THE  CHEST, 

the  middle  with  the  outer  third  of  the  clavicle,  passing 
an  inch  to  the  outer  side  of  the  nipple. 
Contents : 

MIGHT  SIDE,  the  lung,  right  lobe  of  the  liver,  right 
auricle,  right  ventricle,  and  diaphragm. 

LEFT  SIDE,  the  lung  and  heart. 

INFRA-MAMMARY  regions.  n^ 

Boundaries : 

ABOVE,  the  lower  border  of  the  sixth  rib. 
BELOW,  the  lower  border  of  the  false  ribs  and  car- 
tilages (the  costal  arch). 
INTERNALLY,  the  costal  arch. 

EXTERNALLY,  a  line  let  fall  from  the  junction  of 
the  middle  with  the  outer  third  of  the  clavicle. 
Contents : 

BIGHT  SIDE,  the  lung  on  deep  inspiration,  the  right 

lobe  of  the  liver. 
LEFT  SIDE,  the  lung  and  the  left  lobe  of  the  liver. 

SUPRA-STERNAL  region. 
Boundaries: 

ABOVE,  a  line  on  a  level  with  the  first  ring  of  the 

trachea. 
BELOW,  the  inter-clavicular  notch. 
LATERALLY,  the  anterior  borders    of  the    sterno- 
cleido-mastoid  muscles. 
Contents  :  the  trachea,  thyroid  gland,  vessels,  and  oesoph- 
agus. 

SUPERIOR  STERNAL  region. 
Boundaries  : 

ABOVE,  the  inter-clavicular  notch. 
BELOW,  a  line  on  a  level  Avith  the  third  costal  car- 
tilages. 
LATERALLY,  the  margins  of  the  sternum. 
Contents  :  the  lung  below  the  level  of  the  second  costal 


TorooBArnr  of  the  chkst.  21 

cartilage,  the  descending  vena  cava,  aorta,  [)MliiH)iiai-v 
artery,  and  bifun^ation  of  the  traclica. 

INFERIOR-STERNAL  region  inclndes  the  sternnm  below 
the  level  of  the  third  costal  cartilages. 
Contents  :  a  part  of  the  right  auricle  and  the  origins  of 
the  pulmonary  artery  and  aorta  ;  a  small  part  of  the 
left  lung ;  a  part  of  the  right  ventricle,  right  lung  and 
liver,  and  a  part  of  the  attachment  of  the  pericardium 
to  the  diaphragm. 


LATERAL  REGIONS. 

AXILLARY  regions. 
Boundaries : 

ABOVE,  the  axilla. 

BELOW,  a  line  on  a  level  with  the  lower  border  of  the 

mammary  region. 
AWTEBIOBLY,  a  vertical  line  let  fall  from  the  junc- 
tion of  the  middle  with  the  outer  third  of  the  clavicle. 
JPOSTEBIOBLY,  the  anterior  or  axillary  border  of 
the  scapula. 
Contents :    lung-tissue,   and    the   main   bronchi   deeply 
placed. 

INFRA-AXILLARY  regions. 
Boundaries : 

ABOVE,  the  axillary  region. 
BELOW,  the  margins  of  the  false  ribs. 
AJVTEBIOBLY,  the  external  boundary  of  the  infra- 
mammary  region. 
POSTEBIOBLY,  a   line  let  fall    from    the   inferior 
angle  of  the  scapula  (scapular  line). 
Contents  : 

EITHER  SIDE,  lung- tissue. 

BIGHT  SIDE,  the  right  lobe  of  the  liver. 

LEFT  SIDE,  the  spleen  and  part  of  the  stomach. 


22 


PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 


Fig.  5.— Posterior  surface  of  the  chest. 


POSTERIOR  REGIONS. 
SUPRA-SCAPULAR  regions. 

Boundaries,  those  of  the  supra-spinous  fossse. 
Contents :  the  apices  of  the  lungs. 

SCAPULAR  regions. 

Boundaries,  those  of  the  infra-spinous  fossse. 
Contents :  lung-tissue. 

INTER-SCAPULAR  region. 
Boundaries  : 

EXTERNALLY,  the  posterior  borders  of  the  scapulae. 
The  region  extends  from  the  level  of  the  second  to 
that  of  the  seventh  dorsal  vertebra. 
Contents : 

BIGHT  SIDEf  the  lung,  bronchial  glands^  and  main 
bronchus. 


LANDMARKS   OF  TlIK  CHEST.  23 

LKt'T  SE Die,  the  lung,  glands,  main   In-oiicluis,  aorta, 
thoracic  duct,  and  (lesopliagus. 

INFRA-SCAPULAR  regions. 
Boundaries  : 

ABOVE,  inter-scapular  and  scapular  regions. 
BELOW,  the  margins  of  the  false  ribs. 
POSTEIilORLY,  the  spines  of  the  dorsal  vertebrae, 

below  the  seventh. 
ANTERTOliLY,  the  scapular  line. 
Contents : 

BIGHT  SIDE,  the  liver,  lung,  and  upper  end  of  the 

kidney. 
LEFT  SIDE,  the  lung  and  a  part  of  the  spleen,  kid- 
ney, and  intestines. 


LANDMARKS  OF   THE   CHEST. 

The  landmarks  inclnde  the  various  points,  lines,  and 
measurements  to  which  reference  may  be  made  in  showing 
the  relation  of  the  deep  organs  to  the  surface. 

LINES  OF  EEFERENCE. 
VERTICAL  lines  of  reference. 

Meso-sternal  line,  the  mid-line  of  the  sternum. 

Sternal  lines,  right  and  left,  corresponding  to  the  lateral 
margins  of  the  sternum. 

Mammillary  (not  mammary)  hues,  right  and  left,  passing 
vertically  through  the  nipples. 

Para-sternal  lines,  right  and  left,  passing  vertically  mid- 
way between  the  mammillary  and  sternal  lines  on  the 
respective  sides. 

Anterior  Axillary  lines,  right  and  left,  passing  vertically 
through  the  points  at  which  the  pectorales  majores  leave 
the  chest,  the  arms  being  at  right  angles  to  the  body. 

Posterior  Axillary  lines,  right  and  left,  passing  vertically 


24  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

througli  the  points  at  which  the  latissiinus  dorsi  leave 

the  chest,  tlie  arms  being  at  right  angles  to  the  body. 
Mid-axillary  lines,  right  and  left,  midway  between  the 

anterior  and  posterior  axillary  lines. 
Scapular  lines,  right  and  left,  passing  vertically  through 

the  inferior  angles  of  the  scapulae. 
Vertebral  line,  passing  through  the  spines  of  the  vertebrae. 

HORIZONTAL  line  of  reference. 
Horizontal  Nipple  Line. 

OBLIQUE  line  of  reference. 

Linea-costo-articularis,  drawn  from  the  left  sterno- 
clavicular articulation  to  the  free  end  of  the  left 
eleventh  rib. 


LANDMARKS  OF  THE  LUNGS. 

OUTLINE  of  the  lungs. 

Outline  of  the  Right  Lung. 

THE  AJPEX  extends  an  inch  and  a  half  above  the  first 
rib,  and  is  apt  to  be  a  little  lower  than  the  apex  of 
the  left  lung. 

THE  ANTERIOH  BOJRHER  lies  in  the  meso-sternal 
line  from  the  level  of  the  second  to  the  level  of  the 
sixth  costal  cartilage. 

THE  INFERIOR  BORDER  in  adults  lies  as  follows, 
in  the  average  position  ;  on  deep  inspiration  it  is  de- 
pressed an  inch  and  a  half  lower ;  in  children  it  is 
from  a  half  to  a  full  interspace  higher ;  in  the  aged 
it  is  often  as  much  lower : 
IN  THE  MAMMILLARY  LINE  at  the  sixth  rib. 
IN  THE  MID- AXILLARY  LINE  at  the  eighth  rib. 
IN  THE  SCAPULAR  LINE  at  the  tenth  rib. 
Outline  of  the  Left  L^ung. 

THE  APEX  extends  one  inch  and  a  half  to  two  inches 
above  the  first  rib. 


LANDMARKS  OF  THE  CHEST.  25 

TUB  ANTElilOR  BORDEli  lies  in  the  meso-sternal 

line  IVoni  the  level  of  the  seeond  to  the  level  of  the 

fourth  costal  cartilage. 
THE   INFERIOR   BORDER  lies    (in    the    average 
position), 

IN  THE  MESO-STERNAL  LINE,  at  the  fourth  costal 
cartilage. 

IN  THE  PARA-STERNAL  LINE,  at  the  fifth  rib. 

IN  THE  MAMMILLARY  LINE,  at  the  sixth  rib. 

IN  THE  MID- AXILLARY  LINE,  at  the  eighth  rib. 

IN  THE  SCAPULAR  LINE,  at  the  tenth  rib. 
The  inferior  border  of  the  left  lung  reaches  half  to 

three-quarters  of  an  inch  lower  than  the  right  in  the 

mid-axillary  and  scapular  lines. 

FISSURES  of  the  lungs. 

Fissures  of  the  Right  Lung. 
THE  LONG  FISSURE. 

ITS  POSITION  :  it  separates  the  lower  from  the  mid- 
dle and  upper  lobes. 
ITS  DIRECTION  is  from  above  and  behind,  obliquely 

downward  and  forward. 
ITS  RELATION  to  the  chest  is  about  as  follows  : 
Near  the  Vertebral  Column   it   is    three   inches 
below  the  apex  of  the  lung  (near  the  inner  end 
of  the  spine  of  the  scapula). 
In  the  Mid-axillary  Line  it  is  about  the  level  of 

the  fourth  rib. 
^Tiist  within  the  Mamniillary  Line    it    cuts  the 
lower  margin  of  the  lung  at  the  sixth  rib. 
THE  SHORT  OR  LESSER  FISSURE. 

ITS  POSITION  :  it  separates  the  upper  from  the  mid- 
dle lobe. 
ITS  DIRECTION  is  obliquely  dow^nward  and  forward 
from  a  point  near  the  anterior  border  of  the  scapula, 
where  it  joins  the  long  fissure. 


26  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

ITS  RELATION  to  the  cLest-wall  is  about  as  follows  : 
It  lies  at  lirst  nearly  under  the  third  rib^  but  crosses 
the  third  intercostal  space  about  the  mammillary 
line,  and  cuts  the  anterior  border  of  the  lung  about 
the  junction  of  the  fourth  costal  cartilage  with  the 
sternum. 
Fissure  of  the  Left  Lung. 

THE  LONG  FISS  THE  (the  left  lung  has  but  one  fissure). 
ITS  POSITION  :  it  separates  the  upper  from  the  lower 

lobe. 
ITS  DIRECTION  is  from  above  and  behind,  obliquely 

downward  and  forward. 
ITS  RELATION  to  the  chest-wall  is  as  follows  (in  the 
average  position) : 
Near  the   Vertebral   Column    it   is   about   three 

inches  below  the  apex  of  the  lung. 
In  the  3Ii(l-axillary  Line  it  is  about  the  level  of 

the  fourth  rib. 
In  the  3Iainmillarf/  Line  it  cuts  the  lower  mar- 
gin of  the  lung  at  the  sixth  rib. 

LOBES  of  the  lungs. 
Anteriorly  : 

OJSr  THE  MIGHT  SIDE, 

THE  UPPER  LOBE  lies  above  the  third  intercostal 

space. 
THE   MIDDLE   LOBE  lies  below  the  third  interspace, 

reaching  to  the  lower  margin  of  the  lung. 
THE  LOWER  LOBE  is  practically  absent  anteriorly. 
ON  THE  LEFT  SIDE, 
THE    UPPER    LOBE   reaches   from  the  apex  to  the 

lower  margin  of  the  lung. 
THE  LOWER  LOBE  is  practically  absent  anteriorly. 
Laterally  : 

ON  THE  BIGHT  SIDE, 

THE  MIDDLE  LOBE  is  present  above  the  fourth  rib. 


LANDMARKS   OF   Till':   (UKST.  27 

THE  LOWER   LOBE   rcjuilios  fVoiii    tlic   fourth    ril>   to 
the  lower  margin  of  the  hiii^-. 

ON  Till:  LEFT  Sim:, 

THE  UPPER  LOBE  lies  above  the  fourth  rib. 
THE  LOWER  LOBE  reaches  from   the   fourtli  rib  to 
the  h)wer  margin  of  the  hmg. 
Posteriorly  : 

OX  BOTH  STDKS, 
THE  UPPER  LOBE  practically  lies  above  the  spine 

of  the  scapula. 
THE   LOWER    LOBE  reaches  from  the  spine  of  the 
scapula  to  the  lower  margin  of  the  lung. 

THE  TRACHEA. 
Dimensions. 

LENGTH,  four  and  one-half  inches. 
CALIBRE,  three-fourths  to  one  inch. 


A  A 


Median  Line 


Fig.  6— Showing  divergence  of  main  bronchi. 

Bifurcation,  under  the  middle  of  the  sternum  about  the 
level  of  the  second  costal  cartilage,  at  the  level  of  the 
third  dorsal  vertebra.  The  septum  or  line  of  divergence 
between  the  two  bronchi  is  to  the  left  of  the  median 
line,  thus  influencing  the  direction  of  foreign  bodies 
which  enter  the  trachea. 


28  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

THE  PRIMARY  BRONCHI. 
Direction. 

THE  RIGHT  bronchus  is  nearly  horizontal. 

THE  LEFT  bronchus  is  oblique. 
Position. 

THE  BIGHT  lies  under  the  second  rib. 

THE  LEFT  lies  under  the  second  intercostal  space. 
Length.  \ 

THE  MIGHT  is  about  one  inch  long. 

THE  LEFT  is  nearly  two  inches  long. 
Calibre. 

THE  MIGHT  bronchus  is  larger  than  the  left. 


Fig.  7.— Relations  of  the  heart  (Holden). 
LANDMARKS  OF  THE   HEART. 
OUTLINE  of  the  heart.     ^ 

The  Base  nearly  corresponds  in  level  with  the  superior 
margin  of  the  third  rib. 


LANDMARKS  OF  THE  CHEST.  2ii 

The  Apex  lies  under  the  fifth  intercostal  space, 

TIFO  INCHES  BELOW  the  nipple  (in  the  male)  and 
HALF  AN  INCH  TO  THE  RIGHT  of  the  left  mam- 
millary  line. 

The  Right  Margin  corresponds  with  a  line  beginning  on 
the  third  costal  cartilage  half  an  inch  to  the  right  of 
the  right  sternal  line,  curving  slightly  to  the  right  and 
downward  to  the  end  of  the  sternum. 

The  Left  Margin  corresponds  with  a  line  Ijeginning  on 
the  third  costal  cartilage  an  inch  to  the  left  of  the  left 
sternal  line,  curving  to  the  left  and  downward  to  the 
apex  beat,  but  not  including  the  nipple. 

The  Lower  Margin  corresponds  nearly  with  a  line  join- 
ing the  apex  and  the  end  of  the  sternum. 

RELATION  of  the  heart  to  the  lung  in  front. 

It  is  Covered  by  the  lung  (Gardiac  dulness)  from  the 
upper  margin  of  the  third  to  the  lower  margin  of  the 
fourth  rib,  and  below  the  fourth  rib  between  the  para- 
sternal line  and  the  left  margin  of  the  heart. 

It  is  Uncovered  by  the  lung  {cardiac  flatness)  in  the  tri- 
angular or  irregularly  quadrilateral  area  bounded  on 
the  right  by  the  meso-sternal  line,  on  the  left  and  above 
by  a  line  drawn  from  the  fourth  costal  cartilage  to  a 
point  a  little  to  the  right  of  the  apex  beat. 

VALVES  of  the  heart. 
Position  (Gray). 

semilunah  valves. 

THE  PULMONIC  valve  lies  behind  the  left  sternal 
line  at  the  level  of  the  third  costal  cartilage. 

THE  AORTIC  valve  lies  close  to  the  left  sternal  line, 
behind  the  third  intercostal  space. 

auriculo-ventricular  valves. 

THE  TRICUSPID  valve  lies  behind  the  meso-sternal 
line  about  the  level  of  the  fourth  costal  cartilage. 


30  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

THE  BICUSPID  or  mitral  valve  lies  about  one  inch 
to  the  left  of  the  sternum  behind  the  third  inter- 
costal space. 

LANDMAEKS  OF  THE  AOKTA. 

The  aorta  is  most  superficial  in  the  right  second  intercostal 
space  at  the  edge  of  the  sternum.  The  arch  of  the  aorta 
lies  an  inch  below  the  inter-clavicular  notch. 

LANDMAEKS  OF  THE  INNOMINATE  AETEEY. 
Its  course  may  be  traced  by  an  oblique  line  drawn  from 
the  mid-sternal  line  at  the  level  of  the  second  costal  cartilage 
to  the  right  sterno-clavicular  articulation. 

LANDMAEKS  OF  THE  LIVEE. 

RIGHT  LOBE  of  the  liver. 
Its  Upper  Margin  lies, 

IJ^  THE  3IAM3IILIjARY  LINE,  at  the  fourth  in- 
tercostal space. 
IN  THE  MID-AXILLABY  LINE,  at  the  sixth  rib. 
IN  THE  SCAPULAR  LINE,  at  the  eighth  rib. 
Its  Lower  Margin  lies  half  an  inch  beloAV  the  costal  arch, 

in  the  average  healthy  adult  male. 
Relation  of  the  liver  to  the  lung. 

IT  IS  COVERED  by  lung  {hepatic  dulness), 

IIM  THE  MAMMILLARY  LINE,  from  the  fourth  inter- 
space to  the  sixth  rib. 
IN  THE  MID- AXILLARY  LINE,  from  the  sixth  to  the 

eighth  rib. 
IN   THE  SCAPULAR    LINE,  from  the  eighth  to  the 
tenth  rib  (the  lower  margin  of  the  lung  may  be 
depressed  an  inch  and  a  half  on  deep  inspiration). 
IT  IS  UNCOVEREn  by  lung  {hepatic  flatness)  from 
these   points  (sixth,   eighth,   and  tenth  ribs)  down- 
ward. 


LANDMARKS  OF  THE  CHEST.  31 

LEFT  LOBE  of  the  liver. 

Its  Upper  Margin  lies  under  and  against  the  diaphragm, 
adjoining  the  heart. 

Its  Lower  Margin  (in  the  median  line)  lies  about  mid- 
way between  the  end  of"  the  appendix  sterni  and  the 
umbilieus. 

Its  Left  Margin  reaehes  nearly  to  the  left  manunillary 
line. 

LANDMAKKS  OF  THE  SPLEEX. 
THE  SPLEEN  IS  COMPLETELY  SHELTERED  Ixnealli 
the  ribs,  and  cannot  be  felt  in  health  except  in  rare  cases. 
THE  OUTLINE  of  the  spleen. 

Its  Upper  Margin  lies  under  the  ninth  rib. 
Its  Lower  Margin  lies  under  the  eleventh  ril). 
Its  Anterior  Extremity  nearly  reaches  the  linea  costo- 
articularis,  drawn  from  the  free  end  of  the  eleventh  rib 
to  the  left  sterno-clavicular  articulation. 
Its  Posterior  Extremity  approaches  within  two-thirds 
of  an  inch  of  the  body  of  the  tenth  dorsal  vertebra. 

THE  DIRECTION  is  obliquely  backward  and  upward,  the 
long  axis  corresponding  nearly  with  the  direction  of  the 
tenth  rib. 

THE  RELATION  of  the  spleen  to  the  lung. 

It  is  Covered  by  lung  in  its  posterior  and  upper  third, 
which  lies  in  the  infra-scapular  region. 

It  is  Uncovered  by  lung  in  its  anterior  and  lower  two- 
thirds,  which  lie  chiefly  in  the  infra-axillary  region. 

LANDMARKS  OF  THE  VEKTEBR^. 

THE  SEVENTH  CERVICAL  VERTEBRA,  vertebra 
prominens,  is  readily  made  out. 

THE  TWELFTH  DORSAL  VERTEBRA  may  be  located 
by  reference  to  the  twelfth  rib,  which  may  be  felt  when 
the  lumbar  muscles  are  relaxed ;  in  muscular  subjects  it 


32  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

may  be  located  by   following  the  lower   margin  of  the 
trapezius  muscle. 

ALL  THE  SPINES  are  located  by  slight  friction  with  the 
finger,  reddening  the  skin  over  their  tips. 

SLIGHT  CURVATURE  of  the  vertebral  column  to  the 
right  or  left  exists  in  right-  or  left-handed  persons. 

LANDMAEKS  OF  THE  EIBS. 

THE  SECOND  RIB  is  on  a  level  with  the  prominence  (angle 
of  Lewis),  more  or  less  marked  in  all  persons,  at  the  junc- 
tion of  the  first  and  second  pieces  of  the  sternum. 

THE  SEVENTH  RIB  lies  at  the  inferior  angle  of  the  scap- 
ula when  the  arms  hang  at  the  sides. 

THE  FIFTH  RIB  is  just  covered  by  the  convex  lower  bor- 
der of  the  pectoral  is  major. 

THE  THIRD   COSTO-STERNAL   JUNCTION   is  on  a 

level  with  the  body  of  the  sixth  dorsal  vertebra. 

THE  HORIZONTAL  NIPPLE  LINE  cuts  the  sixth  inter- 
costal spaces  in  the  mid-axillary  lines. 

THE  ELEVENTH  AND  TWELFTH  RIBS  can  always  be 
felt  when  the  abdominal  wall  is  relaxed. 

THE  INFERIOR  END  OF  THE  STERNUM  is  on  a  level 
with  the  tenth  dorsal  vertebra. 

LANDMAEKS  OF  THE  SCAPULA. 

The  scapula  lies  over  the  ribs  from  the  second  to  the 
seventh.  The  inner  end  of  the  spine  of  the  scapula  is 
nearly  on  a  level  with  the  third  dorsal  vertebra,  main 
bronchus,  and  beginning' of  the  pulmonary  fissures  behind. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  ',V^ 

METHODS   OF   PHYSICAL   DIAGNOSIS. 

The  methods  of  physical  examination  are  inspection,  pal- 
pation, mensuration,  percussion,  auscultation,  and  succussion. 

INSPECTION. 
Inspection  reveals  color,  nutrition,  size,  form,  posture,  and 
movements. 

COLOR  may  be  due  to  pigmentation,  or  vascularization,  or 
both. 
Color  dependent  upon  pigmentation  may  be 
NOR3IAL, 

LOCAL,  as  in  the  areola?  about  the  nipples,  color  of 

the  eyes  and  hair. 
GENERAL,  as  in  the  Negro,  Malayan,  Indian,  bru- 
nette, and  blonde. 
ABNORMAL. 

LOCAL,  moles,  lentigo,  chloasma,  the  seat  of  scars, 

leucoderma. 
GENERAL,  icterus,  argyria,  Addison's  disease. 
Color  dependent  upon  vascularization. 

XOB3IAL^  erythema,  ruddy  complexion  or  the  opposite. 
ABNORMAL. 
LOCAL. 

Arterial,  congestion,  eruptions,  etc. 
Venous,  ecchymosis,  enlarged  superficial  veins  and 
capillaries. 
GENERAL. 

Arterial,  congestion,  or  its  opposite,  pallor,  chloro- 
sis, anaemia. 
Venous,  cyanosis,  morbus  cseruleus. 
Color  dependent  upon  both  vascularization  and  pigmenta- 
tion is  observed  in  various  cachexise,  malignant  disease, 
disease  of  the  liver,  etc. 
NUTRITION  is  manifested  by  the  degree  of  fatty  deposits 
or  nuiscular  development,  as  well  as  by  the  color. 


34 


PHYSICAL  DIAGNOSIS   OF  THE  CHEST. 


SIZE  of  the  chest. 

Normal  size  of  the  chest. 

CIBCUMFEBENCE  of  the  chest  at  the  level  of  the 
nipples  in  man,  just  above  the  mammse  in  women. 
AVERAGE  circumference  thirty-four  inches  in  men, 

thirty-two  in  women. 
USUAL  E XT R E M  ES,  twenty-eight  to  forty-four  inches. 

Chest-measurement  as  related  to  Height  and  Weight. 


Height. 

Chest 

Standard 

20  per  cent. 

45  per  cent. 

Weight. 

under  weight. 

over  weight. 

5  feet  

33J 

115 

92 

167    ' 

5  "  1  in.  .  .  . 

34 

120 

96 

174 

5  "  2  "  .  .  . 

35 

125 

100 

1811 

5  "  3  "  .  .  . 

36 

130 

104 

188* 

5  ''  4  "  .  .  . 

36J 

135 

108 

195 

5  "  5  "  .  .  . 

37 

]40 

112 

203 

5  "  6  «  .  .  . 

37i 

143 

1]4 

207 

5  "  7  "  .  .  . 

38 

145 

116 

210 

5  "  8  "  .  .  . 

38i 

148 

119J 

215 

5  "  9  "  .  .  . 

39 

155 

124 

224^ 

5  "  10  "  .  .  . 

m 

160 

128 

232 

5  "  11  "  .  .  . 

m 

165 

132 

239 

6  "   

41 

170 

136 

246 

RESPIRATORY  EXPANSION,  two  to  seven  inches. 
Average  of  the  chest,  two  inches  and  a  half. 
Usual  Extremes,  two  to  four  inches. 
SE3II-CinCV3IFEIiENCE  laterally. 

THE  RIGHT  SIDE  is  usually  half  an  inch  larger  than 
the  left  in  right-handed  persons. 
Abnormal  size  in 

CIRCU3IFEnENCE ;  this  may  be  disproportionately 
SMALL  compared  with  the  vertical  diameter  of  the 
chest,  when  it  is  generally  associated  with  flatness 
or  hollowness  of  the  upper  anterior  part  of  the 
chest,  wing-like  projection  of  the  scapulae,  an  acute 
costal  angle,  and  deficient  respiratory  expansion. 
The  circumference  is  apt  to  be  disproportionately 


METHODS  OF  PHYSICAL   DIAGNOSIS.  Zh 

LARGE  in  marked  emphysema. 
SEMI-€lIiCUMFERENCE ;  either  side  of  the  chest 
may  be 
SMALL  compared  with  the  other,  as  a  result  of  fibroid 
contractions  of   the   lung  on  that  side,  following 
pleurisy,  pneumonia  or  collapse.     It  may  be 
LARGE  as  compared  with  the  other,  in  case  of  exten- 
sive pleuritic  effusion  or  pneumothorax. 
FORM  of  the  chest. 

Normally  the  chest  is  a  nearly  symmetrical,  truncated, 
conical  pyramid,  flattened  slightly  in  its  antero-posterior 
diameter. 
Abnormal  forms  of  the  chest. 
ASYMMETRIC AIj  forms. 

LOCAL  BULGINGS  may  be  due  to  irregularities  of  the 
*  Chest-wall ;  tumors  or  swellings  such  as  sarcoma, 

abscess,  periostitis,  or  deformities  of  the  bony 
framework. 
Pressure  from  within,  due  to  the 
Thoracic  Organs. 
Circulatory  organs. 

Enlargement  of  the  heart  in  children. 
Hydro-  or  pneumo-pericardium,  aneurysm. 
Lungs  and  Mediastinum. 
Tumors  or  sw^ellings. 

Pleuritic  accumulation  of  gas,  fluid,  or  solids, 
e.  g,  pneumothorax,  serothorax,  tumors. 
Abdominal  Organs. 

Enlargement  of  abdominal  organs. 
Abnormal  accumulation  of  gas,  fluid,  or  solids, 
encroaching  upon  the  thorax. 
LOCAL  DEPRESSIONS,  as  the  retraction  of  the  supra- 
and  infra-clavicular  regions  from  contraction  of  the 
apex  of  the  lungs  in  phthisis ;  or  the  retraction  of 
the  chest  in  any  region  following  fibroid  induration 
of  the  lung. 


36  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

RELATIVELY  SYMMETRICAL  forms  of  the  ab- 
normal chest. 

THE  PIGEON  BREAST  deformity  of  the  chest  occurs 
chiefly  in  childhood^  and  is  characterized  by  lateral 
constriction  of  the  thorax,  with  straightening  of 
the  true  ribs  and  prominence  of  the  lower  end  of 
tlie  sternum  ;  this  is  a  result  of  rhachitis. 

THE  RHACHITIC  CHEST  is  de^veloped  in  early  life  ;  it 
is  characterized  by  lateral  retraction  of  the  thoracic 
walls,  the  anterior  surface  being  broader  than  in 
the  pigeon  breast,  and  the  sternum  less  prominent ; 
the  costo-chondral  junctions  are  thickened,  pre- 
senting a  series  of  bead-like  eminences  known  as 
the  rhachitlc  rosary, 

THE  ALAR  CHEST  is  characterized  by  ving-Iihe  pro- 
jections of  the  scapulae,  usually  associated  witli  a^ 
narrow  chest,  sloping  shoulders,  and  an  acute  costal 
angle.  It  is  commonly  significant  of  constitutional 
weakness,  which  favors  the  development  of  pul- 
monary phthisis. 

THE  EMPHYSEMATOUS  OR  BARREL-SHAPED 
CHEST  is  characterized  by  roundness  of  contour, 
the  antero-posterior  diameter  being  lengthened,  the 
transverse  diameter  shortened,  and  the  upper  end 
of  the  sternum  prominent ;  the  intercostal  spaces 
are  wide  and  full,  the  shoulders  are  thrown  for- 
ward, the  scapulae  separated,  and  the  whole  pos- 
ture stooping. 

FUNNEL  BREAST,  characterized  by  sinking  in  of  the 
lower  end  of  the  sternum,  is  a  congenital  deformity 
sometimes  observed  in  several  branches  of  the  same 
family  ;  it  may  be  so  marked  as  to  interfere  seriously 
with  respiration.  Shoemakers^  breast  is  an  acquired 
deformity  of  similar  form,  and  is  caused  by  the 
pressure  of  tools  against  the  lower  part  of  the 
sternum. 


METHODS  OF  PHYSICAL  DIAGNOSIS  37 

HARRISON'S  GROOVE  is  a  horizontal  line  of  depres- 
sion along  the  false  ribs,  corresponding  to  the  in- 
sertion of  the  diaphragm  ;  it  is  sometimes  observed 
in  conditions  of  chronic  inspiratory  dyspnoea  neces- 
sitating powerful  action  of  the  diaphragm,  especially 
in  rhachitic  children. 

SPINAL  curvatures;  the  chest  may  be  asymmet- 
rical or  symmetrical,  deviations  being  either  antero- 
posterior or  lateral,  or  both.  These  may  be  due 
either  to  defective  development  of  the  bodies  of  the 
vertebrae  or  to  caries. 

POSTURE.     The  position  of  the  body  as  a  whole  or  in  its 
parts  is  significant  as  an  aid  to  diagnosis. 
Voluntary  posture,  as  ordered  by  the  examiner. 
NATURAL  postures. 

FIXED  position,  upright,  standing,  sitting,  recumbent. 
CHANGE  from  the  upright  posture  to  recumbency 
may  reveal  movable   organs,  fluids   or   gases,    or 
evidence  of  pain. 
UJVNA TUBAL  or  specially-arranged  postures  to  facil- 
itate examinations — genu-pectoral,  left  lateral  semi- 
prone,  etc. 
Involuntary  posture,  as  assumed  by  the  patient  as  a  re- 
sult of  disease. 
r  OS  TUBE  OF  THE  BODY  AS  A  WHOLE. 

DROOPING,  relaxed,  or  reclining  posture  as  indicat- 
ing lassitude,  debility,  helplessness. 
FORWARD,  BACKWARD,   OR    LATERAL  inclination 
more  or  less  fixed,  as  a  result  of 
Brolonf/ed  Habit,  or  from  occupation. 
PartUd  Desfruction  ftf  the  Bony  Suirport  (Pott's 

disease,  etc.). 
Muscular  Contraction  from 

Infj.ammation  of  the  soft  parts,  and 
Abxormal  Prp:ssures  from  tumors  or  enlarged 


38  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

organs — viz.  forward  inclination  to  relieve  the 
backward  pressure  of  an  aneurysm  or  other 
tumor  against  the  trachea,  marked  flexion  of 
the  body  in  peritonitis,  colic,  etc. 
Lesions  of  the  Central  or  Peripheral  Nervous 
System  may  produce  opisthotonos  or  over-exten- 
sion of  the  vertebral  column  from  tonic  contrac- 
tion of  the  posterior,  cervical,  dorsal,  and  lumbar 
muscles,  with  associated  extension  of  the  thighs 
and  extension  of  the  legs  in  tetanus,  spinal  menin- 
gitis, hysteroid  convulsions. 
RECUMBENCY  UPON  OR    INCLINATION  TOWARD 
THE  AFFECTED  SIDE  is  common  in  the  first  stage 
of  pleurisy. 
INABILITY  TO    LIE   ON    THE   AFFECTED   SIDE    in 
many  cases  of  pleurisy  with  effusion,  and  in  case 
of  superficial  inflammations,  or  in   some  cases  of 
cardiac  disease. 
INABILITY  TO  LIE  DOWN  AT  ALL  in  certain  cardiac 
and  pulmonary  diseases  interfering  with  respira- 
tion— viz.  asthma. 
POSTURE  OF  THE  BODY  IN  ITS  PARTS. 
FIXED   POSITION   of  the  limbs  in  any  position  in 

catalepsy. 
LIMBS  RELAXED  or  parts  of  the  body  drawn  to  the 

opposite  side  in  unilateral  paralysis. 
LIMBSOR  HEAD  DRAWN  INTO  DISTORTED  POSI- 
TIONS by  muscular  or  fibroid  contractions. 
POSITION    OF   A    LIMB    involuntarily    corresponds 
to     that    giving    least    pain    in    disease    of    the 
joints. 
FACIAL  EXPRESSION  is  closely  related  to  posture, 
and  depends  largely  upon  the  influence  of  the  in- 
tellect, feeling,  and  will. 

Intellectual,  expression   of  intelligence  or   imbe- 
cility, etc. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  39 

Er¥iotional,  expression  of  pain,  anxiety,  fear,  grief, 

anger,  joy,  etc. 
7  olitlonal. 

Voluntary  control  in  the  change  of  expression. 
Involuntary  distortion   of  features  as   seen   in 
paralysis  and  contraction. 

MOVEMENTS. 

General   nuiscular  movements  are  of   interest  as  being 
normally  or  abnormally  present  or  absent,  as  in  paralysis 
and  chorea,  or  as  eliciting  pain. 
GAIT  is  peculiar  in  various  diseases  of  the  central  or 

peripheral  organs. 
CONVULSIONS  OR  TRE3IOBS  may  be  present. 
COUGHING,  SNEEZING,  SNORING,  SIGHING, 
YA  WNING,  AND  HICCO  UGH,  while  visible  signs 
as  well  as  symptoms  often  of  disease,  are  better  classed 
with  subjective  features.     Cough  as  a  sign  is  referred 
to  under  Auscultation. 
Respiratory  movements. 

NOR3IAL  breathing  is  termed  eupncea.    The  two  sides 
of  the  chest  should  expand  equally,  and  the  upper 
part  of   the  chest  should    be  Vv'ell  filled   with  each 
inspiration.     There  is  a  slight  falling  in  of  the  inter- 
costal spaces  during  inspiration,  and  a  corresponding 
shallowness  of  these  during  expiration. 
THE  RHYTHM  or  ratio  of  the  inspiratory  to  the  ex- 
piratory aet  is  as  six  to  seven  (Gibson),  there  being 
no  pause  between  them. 
THE  TYPES  of  respiration  include  costal  or  superior 
costal  breathing   as   observed    in  women,  inferior 
costal  breathing  as  usually  observed  in  men,  ab- 
dominal   or    diaphr<t(prw.tic    breathing    as    seen    in 
children. 
THE  RAPIDITY  of  normal  respiration  varies  accord- 
ing to 


U 

per 

minute, 

years 

26 

iC 

u 

20 

ii 

ve" 

18 

u 

Y    " 

16 

a 

'^ 

18 

a 

40  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Intrinsic  Conditions, 

Age. 

Under  one  year, 
One  to  five 
Five  to  twenty 
Twenty  to  twenty-five  ^^ 
Twenty-five  to  thirty 
Thirty  to  fifty 
Physical 

State,  posture. 

Activity,  general  muscular,  digestion,  etc. 
Mental 

State,  temperament. 
Activity,  emotional,  volitional. 
Extrinsic  Conditions, 

Rarity  of  the  Atmosphere,  elevation,  etc. 
Excessive  Heat  acting  on  body-temperature. 
ABNORMAL  breathing  regards  the 
FORM  of  the  chest  during  respiration. 

Edcjiansion  of  the  chest  in  abnormal  breathing. 
Diminished  expansion  may  be  unilateral  or  bi- 
lateral {vide  tlie  conditions  and  causes  of  feeble 
respiration). 
Bulging"  of  the  intercostal  spaces  during  expira- 
tion is  observed  in  emphysema. 
detraction  of  the  soft  parts  of  the  chest,  xiphoid 
process,  and  false  ribs  in  inspiration  occurs  in 
croup,  paralysis  of  the  vocal  cords,  and  other 
conditions   involving  obstruction  of  the   upper 
air-passages. 
RAPIDITY  OF  ABNORMAL  RESPIRATION. 

Ahnornially    Mapid    respiration     is    termed    hy- 

j^erpnoea.     This  is  observed  in  most  conditions 

causing  dyspnoea  (vide),  notably  in  the  following  : 

In  Fever,  especially  in  nervous  persons,  and  in 

children. 


METHODS  OF  PHYSICAL  DIAGNOSIS  41 

In  all  Conditions  Causing  Painful  Breathing-, 

such  a8  diseases  of  the  pleura,  dia})hragm,  aud 

peritoneum,  fracture  of  the  ribs,  pleurodynia. 

In  Diseases  Narrowing  the  Bronchial  Tubes : 

asthma,  bronchitis. 
In  Conditions  Lessening  the  Aerating  and  Cir- 
culatory Areas  of  the  Lungs. 
Pulmonary  Disease:  emphysema,  cedema, 

pneumonia,  etc. 
Pleuritic  Affections  :  air,  fluids,  or  solid 
tumors  in  the  pleural  cavity  pressing  on  the 
lungs. 
Abdominal  Affections  :  tumors,  swellings, 
or  effusion,  or  gas. 
In  Disease  of  the  Heart  affecting  the  pulmonary 

circuit. 
In  some  Diseases  of  the  Nervous  System. 
Abnormalli/  Slow  liespiration  might  well  be 
termed  hypopncea.  This  is  observed  in  the 
course  of  Cheyne-Stokes  respiration,  and  some- 
times in  diseases  of  the  brain  and  meninges;  in 
acute  infectious  diseases  with  marked  mental 
dulness;  in  stenosis  of  the  upper  air-passages, 
due  to  intra-tracheal  tumors,  foreign  bodies,  in- 
flammation, compressions  from  without,  and 
paralysis  of  the  abductors  of  the  vocal  cords. 
S'tispefided  Hespiratiofi  is  termed  ajpncea,  which  is 
due  to  want  of  a  proper  stimulus  to  respiration, 
owing  to  saturation  of  the  blood  with  oxygen 
and  the  presence  of  a  deficient  amount  of  car- 
bonic-acid gas ;  it  is  observed  in  the  course  of 
Cheyne-Stokes  respiration.  It  seems  to  be  the 
condition  of  the  foetus  in  utero. 
Asphyxia  literally  means  absence  of  the  pulse — 
i.  e,  the  almost  pulseless  condition  of  suspended 
vitality  resulting  from  lack  of  oxygen  in    the 


42  PHYSICAL  I) f A  GNOSIS  OF  THE  CHEST. 

blood  or  its  saturation  with  COg.     The  stages  of 
asphyxia  (Landois)  are 
Hyperpnoea,  lasting  about  one  minute. 
Convulsions,  lasting  about  one  minute. 
Exhaustion,  lasting  about  three  minutes,  during 
which  the  heart  continues  to  beat,  but  feebly. 
When  the  heart  ceases  to  beat  recovery  is  im- 
possible. '' 
VARIATION    IN  THE    RHYTHM    OF  RESPIRATION. 
An  increase  in  the  number  or  depth  of  respirations, 
or  both,  is  the  chief  characteristic  of  dyspnoea  or 
difficult  breathing. 
Dyspticea. 

Varieties  of  Dyspncea. 

Inspiratory  dyspnoea :  dyspnoea  may  be 
purely  inspiratory,  or  it  may  be  associated 
with  difficult  expiration  in  varying  degree ; 
it  is  the  result  of  obstruction  to  the  ingress 
of  air  into  the  lung,  and  is  observed  in 
croup,  compression  of  the  trachea,  and 
paralysis  of  the  diaphragm,  etc. 
Expiratory  dyspnoea,  pure,  or  associated 
with  difficult  inspiration,  is  due  to  obstruc- 
tion to  the  exit  of  air  from  the  lung,  as  is 
typically  observed  in  asthma  and  emphy- 
sema. 
Mixed  expiratory  and  inspiratory  dyspnoea  is 
most  frequent ;  it  is  observed  in  many  dis- 
eases of  the  lungs  and  heart,  and  in  fever. 
Exaggerated  dyspnoea,  or  orthopnoea,  re- 
quiring the  sitting  or  standing  posture  and 
the  use  of  the  extra  muscles  of  respiration, 
is  observed  in  acute  asthma  and  in  advanced 
cardiac  disease,  etc. 
Cheyne-Stokes  Respiration  is  character- 
ized by  a  number  of  shallow  respirations 


METHODS  OF  PHYSICAL   DIAGNOSIS  43 

which  become  deeper  and  more  dyspnoeic  to 
a  given  point  at  whieli  there  may  be  a  groan, 
and  then  grow  more  superficial  till  they  ap- 
])arently  cease ;  after  a  pause  (apnoea)  the 
series  is  repeated,  the  whole  cycle  occupying 
from  thirty-five  seconds  to  a  minute,  the 
number  of  respirations  usually  being  about 
thirty.  During  the  pause  the  pupils  are 
contracted  and  inunobile  to  light,  and  con- 
sciousness is  usually  lost.  In  some  cases 
consciousness  returns  with  deep  breathing, 
and  the  pupils  dilate  and  react  to  light. 
This  is  normal  in  animals  during  hiberna- 
tion ;  abnormal  in  man,  due  to  cerebral  or 
medullary  disease  (meningitis,  hemorrhage, 
tumors),  uraemia,  certain  affections  of  the 
heart,  and  to  opium-poisoning. 
Causes  of  DyspncBa, 

Respiratory  causes  of  Dyspncea  may  de- 
pend upon 
Insufficient  quantity  of  air  supplied  to  the 
lungs,  owing  to — 

1.  Imperfect  respiratory  movements,  due 

to— 
(a)  Paralysis,  lesions  of  the  central  or 

peripheral  nervous  system. 
(6)  Pain,    as    in    inflammation    of  the 

pleura  and  peritoneum,  pleurodynia, 

intercostal   neuralgia,  trichinosis  of 

the  diaphragm,  etc. 
(c)    Muvscular  weakness. 
{d)  Yielding  walls  of  the  chest  due  to 

rickets  and  fractures. 
(e)  Loss  of  elasticity  of  the  chest- wall : 

myositis  ossificans,  scleroderma. 

2.  Loss  of  elasticity  of  the  lungs  from 


44  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

emphysema^  pleuritic  adhesion,  pro- 
longed compression. 

3.  Lessened   capacity  of  the    chest,  due 

to— 

(a)  Bony  malformations. 

(b)  Pressure  from  thoracic  or.  abdom- 
inal effusion  or  tumors. 

4.  Lessened  lumen  of  the  air-passages  : 

(a)  Extra-mural  causes  :  cicatricial  con- 
tractions, pressure  of  tumors,  etc. 

(b)  Intra-mural  causes :  thickening  of 
the  walls  of  the  air-passages,  mus- 
cular spasm,  as  in  bronchitis,  asthma, 
and  laryngismus  stridulus. 

{(')  Inter-mural :  foreign  bodies,  secre- 
tions, and  false  membranes  within 
the  air-passages. 

5.  Diminished  surface  for  circulation  and 

interchange  of  gases  in  the  huig, 
owdng  to — 

(a)  Inflammation  of  the  lungs :  pneu- 
monia, fibrosis,  tuberculosis. 

(6)  Collapse  or  compression  of  the  lung 
from  pressure  of  air,  fluid,  or  solids  : 
tumors,  pleuritic  efl'usion,  pneumo- 
thorax. 

(c)  Destruction  of  the  alveolar  capil- 
lary network,  as  in  emphysema. 

Modified  quaJity  of  the.  air  which  is  inhcded. 

1.  Insuflicient  density  due  to  heat,  high 
altitude,  decreased  atmospheric  pres- 
sure. 

2.  Del^eterious  adulterations :  noxious 
gases,  etc. 

3.  Insuflicient  oxygen. 
CiRCULATOEY  CAUSES  OF  Dyspncea  include 


METHODS   OF  PHYSICAL  DIAGNOSIS.  45 

Diminished  quantity  of  blood  aerated ^  owing 
to— 

1.  Oligsemia,  after  acute  lieinorrliage. 

2.  Pulmonary  ischseniia,  from 

(a)  T7.S'  a  f route,  due  to 
PuliiKJiiary     disease :      emphysema, 

fibrosis,  compression,  etc. 
Arterial  disease. 

Extra-mural  :    compression,    liga- 
tion. 

Intra-mural  :  inflammation  of  the 
arterial  coats. 

Inter-mural  :  eml)olism. 

(b)  Vis   a    tergo    may    be    diminished 

owing  to 
Cardiac  inefficiency  from 
Valvular  disease. 
Compression  of  the  heart  by  peri- 
cardiac or  pleuritic  effusion. 
Muscular  weakness  of  the  heart 
from  atrophy,  myocarditis,  de- 
generation, etc. 
Modified  quality  of  the  blood. 

1.  Super-heated  blood  acts  on  the  re- 
spiratory centre,  heat-dyspnoea. 

2.  Deteriorated  blood  :  pernicious  anae- 
mia, fevers,  poisons. 

Circulatory  Movements. 

VASCULAR  MOVEMENTS, 
VENOUS  movements  (pulsations). 
Normal  Venons  Movefiients, 

Jugular  Presystolic  pulsation  (slight)  is  rarely 
visible  in  health  (Vierordt). 
Abnormal  Venous  Movent  en  fs. 

Jugular  Systolic  pulsation  occurs  in  tricuspid 
regurgitation. 


46  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Hepatic  venous  systolic  pulsation  is  sometimes 
visible  in  marked  tricuspid  regurgitation. 
ARTERIAL  movements  (pulsation). 
Normal  Arterial  Movements. 

Carotid  pulsation  is  frequently  visible  under  the 
angle  of  the  jaw,  varying  with  the  degree  of 
adiposity  and  the  force  and  excitation  of  the 
heart. 
Aortic  pulsation  is  exceptionally  visible  in  the 
supra-sternal  region  (high  position  of  the 
arch). 
Abnormal  Arterial  Pulsation, 

Carotid  pulsation,  when   marked,  may  signify 
hypertrophy  of  the  left  ventricle,  insufficiency 
of  the  aortic  valve,  arterial  sclerosis  (aortic), 
or  aneurysm. 
.Aortic  pulsation 

In  the  neck  is  sometimes  due  to  insufficiency 
of  the  aortic  valve,  to  aneurysm,  or  to  hy- 
pertrophy of  the  left  ventricle. 
In  the  eight  second  intercostal  space 
pulsation  is  always  abnormal,  and  is  usually 
significant   of  one   of   the  conditions  just 
mentioned. 
Pulmonary  arterial  pulsation  appears  to  the  left 
of  the  sternum  in  aneurysm  of  this  artery. 
Pulsation   of  this  artery  may  sometimes  be 
seen  in  fibrosis  of  the  lung. 
Capillary  pulsation  (Quincke)  may  be  seen   in 
Marked  hypertrophy  of  the  left  ven- 
tricle, but  more  often  in  marked  aortic 
INSUFFICIENCY.    The  pulsation  is  observed 
in  the  bed  of  the  finger-nails,  at  the  fundus 
of  the  eye,  in  the  mucous  membrane  of  the 
lip  under  pressure  of  a  glass  slide,  and  also 
in  the  line  of  erythema  caused  by  drawing 


METHODS  OF  PHYSICAL   DIAGNOSIS.  47 

the  finger-nail  with  some  force  over  the  ])a- 
tient's  surface. 
CARDIAC  MOVEMENT  (pulsation). 
APEX  BEAT  of  the  heart. 

Cause  of  the  apex  beat :    The  lieart  changes  in 
form,  sliortening  and  thickening,  in  systole,  and 
at  the  same  time  changes  in  position,  revolving 
on  its  axis,  the  apex  being  projected  forward. 
VisibiUff/  of  the  apex  beat. 
Normally  the  visibility  varies  with  tlie 

Shape  of  the   chest  and  the  width   of  the 

intercostal  spaces ; 
Thickness  of  the  chest-wale  from  the 
presence    of    fat,    muscle,    and    mammary 
gland ; 
Posture  of  the  body,  the  apex  being  less 

visible  in  recumbency ; 
Force  of  the  heart's  action,  as  dependent 
upon  its  innate  power  and  its  excitation. 
Abnormally  the  visibility  of  the  apex  beat  varies 
greatly. 
Very  marked  pulsation  is  usually  observed 

in  hypertrophy ; 
Slight  or  absent  pulsation  is  observed  in 
Conditio  us  of  cardiac  iveakness  from 

1.  General  debility,  or 

2.  Local  weakness  of  the  heart\s  muscle, 
dependent  upon  cardiac  atrophy ;  cardiac 
degeneration,  fatty,  fibroid,  or  amyloid ; 
or  cardiac  dilatation. 

Interposition  of  air  between  the  heart  and 
chest-vmll :  emphysema,  pneumothorax, 
pneumo-pericardium  ;  ^w/V? ;  pleuritic  or 
pericardiac  effusion ;  solids :  tumors, 
fibrinous  deposit. 

Thicket  liny  of  the  chest-vmll :  excessive  fat, 


48  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

scleroderma^  oedema,  emphysema  of  the 
chest-wall. 
Blsplaeement  of  the  heart ,  as   by  traction 
from  behind  by  fibroid  contraction. 
Locution  of  the  apex  beat. 

Normal  Location  of  the  Apex  Beat. 

In  the  adult  male  it  is  in  the  fifth  inter- 
costal space,  two  inches  below  and  one  inch 
inside  the  nipple  line. 
Variations  from  the  position  in  the  healthy 
adult  male  accord  with 
Age :  in  children  under  ten  years  the  apex 
beat  is  usually  in  the  fourth  intercostal 
space  inside  or  outside  the  left  mammillary 
line ;  in  old  age  it  is  apt  to  be  lower  down, 
sometimes  in  the  sixth  intercostal  space. 
Respiration.     Deep  inspiration  may  carry  it 

down  to  the  sixth  interspace. 
Posture  on  the 

1.  Left  side,  may  carry  it  to  the  left  of 
the  nipple  line. 

2,  Right  side,  to  the  right  of  the  usual 
position. 

Physical  exertion  or  emotion.    The  apex  beat 

may  become  stronger  or  broader,  or  may 

be  carried  to  the  left  when  the  individual 

is  greatly  excited. 

Abnormal  Location  of  the  Apex  Beat ;  it  may 

be  displaced. 
Upward. 

Pushed  up  by  deformity  of  the  chest- wall ; 
pericardiac  effusion  (here  it  is  apparently 
so) ;  abdominal  tympanitis,  tumors,  and 
ascites  ;  paralysis  of  the  diaphragm. 

Pulled  upward  by  fibroid  contraction  of  the 
upper  lobe  of  the  left  lung. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  49 

Upward  and  to  the  left. 

Fashed  upward  and  to  the  left  by  hyper- 
trophy of  the  left  lobe  of  the  liver  or  by 
abdominal  tumors. 
Pulled  by  fibroid  contractions  of  the  left 
lung. 
Downward  and  to  the  left. 

Pushed  downward  and  to  the  left  by  de- 
formity of  the  chest-wall ;  large  aneurysm 
of  the  arch  of  the  aorta ;  mediastinal  tu- 
mors ;  riglit  pleuritic  effusion  or  pneumo- 
thorax ;  hypertrophy  of  the  left  ventricle 
(strong  apex  beat);  dilatation  of  the  left 
ventricle  (weak  apex  beat). 
Pulled  downward  and  to  the  left  V)y  fibroid 
contractions  of  the  pleura  and  lung. 
To  the  right. 

Pushed  to  the  riglit  Ijy  deformity  of  the  chest- 
wall,  emphysema  of  the  lungs,  leftpleuritic 
effusion,  or  pneumothorax. 
Pulled  to  the  right  by  fibroid  contractions 
of  the  right  lung,  or  held  by  pleuritic 
adhesion. 
Located  on  the  right  side  in  transposition  of 
the  thoracic  organs  (a  rare  condition). 
PRECORDIAL  PULSATION  is  observed  together  with 
the  apex  beat, 
In  Valvular  Disease  frequently  ;  in  cardiac  irrita- 
bility, especially  in  thin  or  young  persons ;  in 
adhesive  pleurisy  with  mediastinal  pericarditis, 
here  there  is  usually  a  systolic  drawing  in  of 
several  intercostal  spaces. 
Til  Infiltration,  of  tJie  Jjiing  lying  in  front  of  the 

heart. 
In  Empyema  Pulsans,  v/hich  may  occur  when 
pus  in  the  pleural  cavity  lies  in  front  of  the 


50  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

heart,  the  cardiac  movements  being  communi- 
cated to  the  fluid.     It  is  probably  favored  by 
paresis  of  the  intercostal  muscles,  high  tension 
in  the  fluid  and  a  powerful  heart. 
EPIGASTRIC  PULSATION. 

Hypertr'02}hy  of  the  Itight  Ventricle,  especially 
if  accompanied  by  pulmonary  emphysema,  fre- 
quently causes  a  systolic  pulsation  or  trembling 
of  the  epigastrium. 

Fulsation  of  the  Normal  Heart  may  be  trans- 
mitted to  the  epigastrium  through  an  hyper- 
trophied  left  lobe  of  the  liver. 

Pulsation  of  tlie  Normal  Aorta  may  be  seen  in 
the  epigastrium  in  thin  persons,  especially  when 
the  stomach  is  empty. 

Pulsation  of  an  Abdominal  Arieiirysm  of  the 
aorta  may  be  visible  in  the  epigastrium. 

Venous  Hepatic  Pulsation^  observed  in  the  epi- 
gastrium, may  occur  in  marked  tricuspid  in- 
sufficiency (rare). 

PALPATION. 

Palpation  is  the  method  of  physical  examination  by  the 
sense  of  touch,  and  it  confirms  much  of  what  has  been  ob- 
tained by  inspection  ;  it  reveals 

SIZE,  SHAPE,  contour,  roughness,  etc. 
CONSISTENCE,  fluctuation, 

MOISTURE  AND   HEAT;  and  elicits 

PAIN. 
Area. 

LOCALIZED,    as  in  intercostal    neuralgia  (Yalleix's 

three  tender  points). 
GENEMAL  sensitiveness,  hypersesthesia. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  51 

Depth. 

SUPERFICIAL. 

SKIN,  inflammation. 
M  use LE ,  pleurodynia. 

FRACTURE  OF  RIBS  (crepitus,  tenderness,  disloca- 
tion). 
DEEB-SEA  TED, 
PLEURA. 

MOVEMENTS. 
Muscular. 
Respiratory. 
Circulatory. 

CARDIAC  MOVEMENTS,  apex  beat,  precordial  pul- 
sation, etc.  {vide  under  inspection). 
EXTENT. 
Localized, 
Diffused. 
CHARACTER. 
Intensity. 
Rhythm, 
VENOUS  MOVEMENTS. 
ARTERIAL  MOVEMENTS  upon  palpation, 
AORTIC  dilating  pulsation  of  aneurysm,  etc. 
CAROTID  pulse. 
RADIAL  pulse. 

Factors  in  the  Production  of  the  Pulse, 
Force  of  the  Heart's  Beat. 
Elasticity  of  the  Large  Vessels. 
Resistance  at   the  Valvular   Orifices  of   the 

heart. 
Resistance  in  the  Arterioles  and  capillaries. 
Volume  of  the  Blood. 
Characteristics  of  the  Pulse,  as  regards 
Quality  of  the  pulse. 

Degree  of  tension  of  the  pulse. 


52  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Increased  or  high  tension  makes  the  incom- 
pressible  or   hard  pulse.     Tension   is 
increased    during     inspiration,     being 
highest : 

1.  At  the  beginning  of  expiration,  except 
in  pulsus  paradoxicus. 

2.  By  accelerated  action  of  the  heart. 

3.  By  stimulation  of  the  vaso  constrictors, 
as  by  the  action  of  cold,  electricity,  and 
certain  drugs. 

4.  By  diminished  outfloAv  of  blood  at  the 
periphery. 

5.  By  disease  of  the  vessel  walls  :  athero- 
ma, sclerosis,  old  age ;  drugs — e.  g. 
lead-poisoning. 

6.  By  compression  of  the  large  arterial 
trunks,  ligation,  or  pressure. 

7.  By  impeded  venous  flow,  as  in  preg- 
nancy, constipation,  chronic  bronchitis, 
emphysema,  nephritis,  etc. 

Decreased  or  low  tension  makes  the  com- 
pressible or  soft  pulse ;  tension  is  de- 
creased during  expiration,  being  lowest : 

1.  At  the  beginning  of  inspiration,  ex- 
cept in  pulsus  paradoxicus. 

2.  After  a  hemorrhage. 

3.  By  stoppage  of  the  heart. 

4.  In  elevated  parts  of  the  body. 

5.  By  stimulation  of  the  vaso  dilators, 
action  of  drugs. 

Degree  of  fulness  of  the  artery  or  volume 
of  the  pulse. 
Increased  volume  of  the  pulse  makes  the 
large  or  full  pulse.  This  is  seen  in  car- 
diac liypertrophy,  plethora,  early  stage  of 
chronic  nephritis. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  53 

Decrea.s('({  vohiiiw  of  the  pulse  makes  the 
small    empty    pulse   as   seen    in   general 
weakness  from   wasting   disease,  cardiae 
weakness,  cardiac  valvular  lesions,  aortic 
stenosis,  mitral  stenosis,  or    marked    in- 
sufficiency without  compensation. 
Alternate  increase  and  decrease  of  the  volume 
of  the  pulse  is  observed  in  aortic  insuf- 
ficiency, giving  the  collapsing  or  icater- 
hammer  pulse  of  Corrigan. 
Force  of  each  pulse-wave  depends  chiefly  upon 
the  energy  of  tlie  cardiac  systole,  and  also 
upon  the  amount  of  vascular  tone. 
Increased  force  of  each  pulse-wave,  making 
the  strong  pulse,  occurs  with  increased  car- 
diac energy  and  vascular  tone. 
Decreased  Force  of  each  pulse-wave,  making 
the  weak  pulse,  is  the  result  of  cardiac  debility. 
Duration  of  each  pulse-w^ave  depends  upon  the 
dilatation  of  the  artery  by  the  blood-current, 
and  its  contraction  during  the  passage  of 
the  blood  into  the  capillaries. 
Prolonged  duration  of  each  pulse-wave, 
giving  the  slow  or  sluggish  pulse,  occurs  in 
all    diseases   producing  contraction  of  the 
smaller  arteries,  as  nephritis,  artero-sclerosis, 
angina  pectoris. 
Shortened  duration  of  each  pulse-wave, 
giving  the  active,  quick  pulse,  is  present  in 
all  diseases  and  conditions  giving  relaxed 
arteries,  as  in  febrile  affections  and  in  aortic 
regurgitation. 
Rhythm  of  the  Pulse. 
Varieties  of  rhythm. 

Irregular  pulse,  as  respects  time,  rate,  and 
volume. 


54  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

1.  Irregular  in  time:  varying  length  of 
successive  intervals  between  beats, 
either  rhythmical  or  arhythmical.  Ir- 
regularity in  rate  may  be  manifested  by 
change  in  rapidity  from  fast  to  slow  or 
vice  versa. 

2.  Irregular  in  volume  :  varying  strength 
or  fullness  of  successive  beats. 

(a)  Pulsus  bigeminus  :  beats  occurring 
in  pairs^  with  intervals  between  each 
pair,  the  second  beat  of  each  pair 
being  weaker  than  the  first. 

(6)  Dicrotic  pulse :  characterized  by  a 
double  beat — i.  e.,  a  large  beat  fol- 
lowed by  a  small  after-beat,  occurring 
with  each  cardiac  systole ;  it  is  a  weak 
pulse  of  low  tension.  It  is  obtained 
in  fever  patients  and  in  some  condi- 
tions of  great  exhaustion. 

(c)  Pulsus  trigeminus  :  groups  of  three 
beats,  the  groups  being  separated  by 
intervals. 

(d)  Intermittent  pulse  :  here  a  beat  is 
dropped  out  or  is  abortive,  cardiac 
systole  not  being  strong  enough  to 
send  through  the  arteries  a  wave  of 
sufficient  size  to  be  felt  at  the  wrist. 

(e)  Pulsus  paradoxicus  :  normally  the 
tension  of  the  pulse  is  increased 
during  inspiration,  but  in  pulsus 
paradoxicus  it  is  decreased  during 
inspiration,  the  pulse  being  very 
small  or  even  absent  at  that  time. 
It  depends  upon  diminished  lumen 
of  the  aorta,  and  notably  occurs  in 
mediastinal     pericarditis,     concretii 


METHODS   OF  PHYSICAL  DIAGNOSIS.  Of) 

perici'irdii,  and   witli    lar^c    pleuritic 
effusion. 
(/)   Irrognlarity   or    incoordination   of 
the  two   radial  pulses  is  sometimes 
observed    in     aortic     aneurysm    or 
aneurysm  of  the  puhiionarv  artery. 
Causes  of  broken  rhythm  of  the  pulse. 
General  causes  of  broken  rhythm. 

1.  Nervous       1 

o    i-r       1  ,         .action  01  druii-s  or  disease. 

2.  Circulatory  J  ^ 

Local  causes  of  broken  rhythm. 

1.  Reflex,  dyspepsia,  etc. 

2.  Circulatory,  diminished  blood  pressure 
in  the  arteries,  as  in  anaemia. 

3.  Cardiac  weakness  from 

(a)  Degeneration,  atrophy,  etc. 
(6)  Mechanical    interference   with    its 
action  ; 
Acting  within  the  cardiac  apparatus, 
due  to  valvular  disease,  pericardiac 
effusion. 
Acting  from  outside  the  heart :  pleu- 
ritic effusion,  distended   stomach, 
hepatic  enlargement,  tumors,  de- 
formities of  the  chest. 
Frequency  of  the  Pulse,   rate  or  number  of 
beats. 
The  average  pulse  rate  in  healthy  adult 
males   is    seventy -one    beats ;    in   females, 
eighty  per  minute ;  the  pulse  is  relatively 
more  rapid  also  in  infancy,  in  small  persons, 
in  the  upright  position,  in  high  altitudes,  in 
late  periods  of  the  day,  after  meals,  during 
emotional  excitement,  intellectual  exercise, 
or  muscular  exertion. 
The  slow  pulse,  bradycardia,  is  character- 


66  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

ized  by  a  rate  of   sixty  beats  or  less  per 
minute ;    it   has   been    observed   as  low  as 
fifteen  beats.     It  is 
No7"mal  in 

1.  Certain  persons,  habitually,  apparently 
inherited. 

2.  Women  immediately  after  child-birth. 

3.  Old  age.  ^ 
Abnormal. 

1.  Symptomatic  in 

(a)  General  diseases  and  conditions  at- 
tended by  great  exhaustion,  e.g.  con- 
valescence from  acute  fevers,  typhoid, 
diphtheria,  pneumonia,  and  in  dia- 
betes and  anaemia. 

(6)  Digestive  tract :  aggravated  dys- 
pepsia, gastric  ulcer,  cancer  of  the 
oesophagus. 

(c)  Urinary  tract :  uraemia. 

(d)  Cardiac  coronary  sclerosis,  myocar- 
dial degeneration,  fatty,  fibroid,  etc., 
aortic  stenosis. 

(e)  Nervous  system. 

Central  diseases  with  gross  lesions, 
as  in  early  stage  of  meningitis, 
apoplexy,  tumors  of  the  cerebrum, 
injuries  to  the  cervical  cord. 

Peripheral,  pressure  upon  the  vagus 
by  tumors,  etc. 

Neuroses,  so-called  idiopathic  disease 
of  the  nervous  system — epilepsy, 
hysteria  in  certain   cases,   mania, 

.general  paresis,  following  fright. 

Toxic:    tea,   coffee,    lead,    uric   acid 
(uraemia),  bile  (jaundice). 
The  rapid  pulse,  tachycardia,  is  character- 


METHODS  OF  PHYSICAL  DIAGNOSIS.  57 

izcd  hy  a  rate  of  eighty-five  beats  or  more 
per  minute ;  it  lias  ])e('ii  observed  as 
liigli  as  two  luni(h'e(l  and  fifty  beats  in 
adults. 
Normally,  the  pulse  is  rapid  in  certain  healthy 
adults  habitually,  and  in  certain  indi- 
viduals who  are  able  voluntarily  to  in- 
crease the  rate  of  the  heart ;  in  women  at 
gestation  :  and  in  children  as  foUows  : 
Infants,  130  to  150. 

One  year  old,       120  to  130. 
Two  years  old,     105. 
Three  years  old,  100. 
Five  years  old,      90  to  94. 

Variations  from  emotions  and  phys- 
ical exercise,  etc.,  vide  the  average 
pulse. 
Ahnormally  rapid  pulse  may  be 
1.  Symptomatic,  arising  from 

{a)  Undue   irritation   of  the  nervous 
system,  as  related  to 
Age  :  young  rapidly-growing  weak 

persons. 
Sex  :  women  usually  at  establishment 
of  menstruation    and   the    meno- 
pause, especially  when  anaemic  and 
chlorotic. 
Habits:  venereal   excess,   masturba- 
tion. 
Toxic  :  tobacco,  alcohol,  tea,  coffee. 
Fatigue  :  physical  or  mental. 
Fever. 
{b)  Lesions    of    the    cardiac    nervous 
mechanism. 
Central :    bulbar   disease    impairing 
the  function  of  the  vagus,  tumors 


58  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

or    swell ingSj     softening     in    the 

medulla  or  cord,  hemorrhage. 
Peripheral :      tumors    or    swellings 

pressing  upon  the  vagus,  neuritis. 
Neuroses. 

Exophthalmic  goitre. 

Epilepsy,  hysteria,  irritable  heart 
of  soldiers. 

Neurasthenia. 
2.  Keflex. 

(a)  Circulatory  :  lesions  of  the  heart  or 
vessels. 

(b)  Respiratory :  nasal  growths  and 
hypertrophies,  pharyngeal  and  laryn- 
geal disorders. 

(c)  Gastro-intestinal :  dyspepsia,  intes- 
tinal Avorms  in  children. 

(d)  Genito-urinary  :  ovarian  and  uter- 
ine disease,  nephritis,  phimosis. 

Fremitus  is  a  trembling  felt  by  the  hand  on  examination. 
It  has  been  termed  fremissement  cataire  from  its  like- 
ness to  the  vibration  felt  upon  the  back  of  a  purring 
cat. 

CIRCULATORY  FREMITUS  or  thrill  is  due  to 
vibrations  originating  within  the  heart  or  great  ves- 
sels, and  it  includes : 

ANEURYSMAL  or  VASCULAR  FREMITUS,  sometimes 
felt  over  large  superficial  aneurysms,  and  occa- 
sionally over  the  carotids  in  valvular  disease  of 
the  heart,  and  over  the  jugular  veins  in  tricuspid 
insufficiency ;  also, 
ENDOCARDIAL  or  CARDIAC  FREMITUS,  not  infre- 
quently obtained,  upon  palpation  of  the  praecordia, 
in  certain  valvular  lesions. 

Causes  of  Cardiac  Freniitiis :  like  certain  cardiac 
murmurs  it  may  be  due  to  the  whirling  of  the 


METHODS  OF  PHYSICAL  DIAGNOSIS  59 

blood-stream  against  a  i-oiiglicucd  siirfacc  or  past 
a  constriction. 
Freqiieni'ff  of  i'm-diac  Fremitus, 

It  generally  occurs  with  loud  cardiac  murmurs, 
but  comparatively   few  nuirmurs  are  accom- 
panied by  a  thrill. 
It   is   most    common  with  mitral    obstruction 

(presystolic)  and  aortic  obstruction  (systolic). 
It  is  more  rare  with  aortic  regurgitation  (dias- 
tolic), mitral  regurgitation  (systolic). 
It  is  very  rare  with  lesions  of  the  right  heart. 
Locatioti  of  CardUic  Frentitus, 

It  is  g-enerally  felt  best  when  the  murmur  is 
heard  loudest — e.  g.,  just  above  the  apex  in 
mitral  obstruction  ;  in  the  aortic  area  in  aortic 
obstruction  and  atheroma ;  over  the  jugulars 
in  case  of  constriction  of  these  vessels  from 
pressure,  as  in  enlargement  of  the  thyroid  gland ; 
over  the  carotids  (systolic)  in  aortic  regurgita- 
tion from  the  sudden  filling  of  the  relatively 
empty  vessels. 
Intensity  of  Cardiac  Freniitus,    . 

It  is  apt  to  be,  like  Murmurs,  increased  by  ex- 
ertion. 
It  may  disappear  in  cardiac  weakness,  and  re- 
turn with  reviving  strength  or  upon  excitement. 
FRICTION  FREMITUS  is  a  rubbing  or  grating  sen- 
sation felt  by  the  hand  in  palpation  over  a  part  where 
two  roughened,  inflamed,  serous  surfaces  are  moving 
upon  each  other,  as  in  the  first  stage  of  pleurisy,  oc- 
casionally in  pericarditis,  and  rarely  in  peritonitis. 
HHOJSTCHAL,  bronchial,  or  rale  FREMITUS 
is  caused  by  the  passage  of  air  through  fluid  in  the 
trachea  and  larger  bronchi  during  respiration  ;    the 
vibrations  produced  are  sometimes  so  marked  as  to 
be  felt  by  the  hand  upon  palpation. 


60  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

CAVERNOUS  FREMITUS :  this  may  sometimes  be 
felt  over  superficial  cavities  in  the  lung^  owing  to  the 
vibration  of  fluid  Avithin  them. 

VOCAL  FREMITUS f  variously  termed   voice  frem- 
itus, vocal  vibration  or  pectoral  fremitus,  is  a  trem- 
bling felt  by  the  hand  when  placed  upon  the  chest  of 
a  person  who  is   speaking  aloud  (tussive  or   cough 
fremitus  is  of  the  same  nature). 
INTENSITY  OF  VOCAL  FREMITUS. 
Increased  or  marked  vocal  fremitus. 
Normal,  is  found  with 

Low  PITCHED  VOICES, 

Strong  voices  ;  near  to  the 

Larynx  ;  over  the 

Teachea  and 

Great  bronchi  ;  it  is  more  marked  over  the 

Eight  apex  of  the  lung  than  over  the  left, 

owing  to  the  size  and  direction  of  the  right 

bronchus ;  it  is  more  marked  over 
Thin  chests  from  the  absence  of  muscle  or 

fat. 
Abnormal,  increased  vocal  fremitus  is  found  : 
Over  consolidation  of  the  parenchyma  of 

the  lung,  when  the  bronchial  tubes,  of  large 

and  medium  size,  are  patulous,  as  obtains  in 

phthisis  and  pneumonia ; 
Over  compressed  or  collapsed  lung  above 

the  level  of  the  effusion ; 
Over  a  cavity  near  the  surface,  with  dense 

walls    and   a    free    opening    into   a   large 

bronchus. 
Diminished  or  Suppressed  vocal  fremitus. 
Normal,  vocal  fremitus  is  weak  or  absent  with 
High  pitched  voices  ; 
Weak  voices; 
Women,  over  lower  half  of  chest ; 


METHODS  OF  PHYSICAL  DLAONOSIS.  61 

Children,  over  tlie  wliole  chest ;  and  at  a 

Distance  from  the  larynx  and  large 
bronchi ;  over 

Thick  chest- walls  from  excess  of  fat,  mus- 
cle, or  mammary  gland. 
Abnormal,  diminished  vocal  fremitus  is  due  to 

Interposition  of 

Fluid,  as  in  hydrothorax,  pleurisy  with  effu- 
sion, etc. ; 
Aivy  as  in  emphysema,  pneumothorax ; 
Solids,  as  in  adherent  and  markedly  thick- 
ened pleura,  large  solid  tumor. 

Obstruction  of  the  large  bronchial 
TUBES  from  the  presence  of  a  foreign  body, 
or  compression  by  a  tumor  or  stricture. 


MENSURATION. 

Measurement  determines  size  and  the  symmetry  or  asym- 
metry of  the  chest ;  in  the  latter  case  it  is  instituted  from  the 
•middle  point  behind  to  the  middle  point  in  front. 

PERCUSSION. 

Percussion  is  the  art  of  eliciting  sounds  by  striking  the 
body. 

METHODS  of  percussion. 

Immediate,  striking  directly  upon  the  part;  this  method 

is  of  comparatively  little  use. 
Mediate,  striking  upon  an  intermediate  object  held  against 

the  part. 

INSTRUMENTS,  in  mediate  percussion  (varieties). 
Hammer,  plexor  or  plessor. 

Pi  ex  i  meter,  or  plessimeter,  the  medium  upon  which  the 
hammer  strikes. 


62  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

THE  NATURAL  and  most  useful  instruments  are  the 
middle  or  index  fingers  of  one  hand^  serving  as  plexor^ 
and  one  or  more  fingers  of  the  other  hand,  as  pleximeter. 

ARTIFICIALLY,  they  may  be  made  of  hard  rubber, 
Avood,  etc. 

RULES  FOR  PERCUSSION. 

The  Patient.  ^ 

THE  SURFACE  should  be  bare  of  clothing. 
THE  LI3IBS  symmetrical,  the   same   position  being 
maintained  in  the  examination  of  the  two  sides. 
TO    EXAMINE   THE    FRONT  of  the  chest  the  arms 

should  be  at  the  sides. 
TO  EXAMINE  THE  BACK  the  arms  should  be  folded 

in  front. 
TO  EXAMINE  THE  SIDES  the  arms  should  be  folded 
above  the  head. 
POSITION  OF  THE  BODY. 

EASE  OF  POSITION,  to  avoid  discomfort  and  to  in- 
sure like  muscular  tension  on  the  two  sides. 
POSTURE  :  the  erect,  recumbent,  or  sitting  posture^ 
or  all  these  may  be  required,  as  in  determining 
change  of  position  of  solid  organs  or  of  the  level 
of  fluids ;  recumbency  must  be  maintained  if  there 
is  danger  of  heart  failure. 
The  Examiner  should  maintain  a  position  symmetrical 
with  regard  to  the  patient,  the  ear  being  at  the  same 
relative  distance  from  the  points  percussed. 
The  Instruments  (their  use). 

THE  PLEXIMETER  should  be  applied 

WITH  FIRMNESS,  to  avoid  a  cushion  of  air  beneath 
it ;  the  firmness  of  pressure  should  be  uniform  at 
all  points  of  percussion. 
PARALLEL  TO  THE  RIBS,  upon  or  between  them. 
OVER  SYMMETRICAL  POSITIONS  on  the  two  sides 
of  the  chest  for  comparison. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  63 

THE  FLEXOR  and  its  use  : 

THE  STROKE  should  ))e  made  WITH  THE  ENDS  OF 
THE  FINGERS  rather  than  witli  their  pulps. 

THE  STROKE  SHOULD  BE  MADE  PERPENDICU- 
LARLY to  the  surfaee. 

THE  STROKE  should  be  REBOUNDING,  in  using  tlie 
hand  the  motion  should  be  from  the  wrist. 

THE  STROKES  should  be  MODERATELY  RAPID  in 
succession. 

THE  STROKE  should  be  made  with  MODERATE 
FORCE,  never  causing  pain,  but  more  forcible  for 
sounding  deep-seated  organs  than  for  superficial. 

THE  TWO  SIDES  SHOULD  BE  PERCUSSED  IN 
LIKE  STAGES  OF  RESPIRATION,  preferably  at 
the  end  of  expiration. 

PERCUSSION  SOUNDS. 

The  Elements  of  Sound  in  percussion. 

Q  UALITYf  the  characteristic  property  or  chief  attribute 
which  distinguishes  one  sound  from  another — e.  g. 
full,  empty,  shallow,  clear,  soft,  hard,  toneless,  dead, 
^^  thigh  sound. '^ 
INTENSITY,  the  quantity  or  loudness,  largely  govern- 
ing the  distance  at  which  a  sound  can  be  heard ; 
varying  w^ith 
THE  FORCE  OF  THE  BLOW. 
THE  VOLUME  OFAIR  under  the  part. 
THETHINNESS  AND  ELASTICITY  OF  THE  CHEST- 
WALL. 
nuitATION,  the   length   of   time   a   sound   can   be 

heard. 
PITCHf  the  degree  of  elevation  in  the  musical  scale. 
ITS  RELATION  to  duration  and  intensity,  the  lower 
the  pitch  the  longer  the  duration,  and  the  greater 
the  intensity,  and  per  contra. 
THE  FACTORS  IN  ITS  PRODUCTION. 


64  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

The  Larger  the  Car  Hies  (containing  gas)  in  the 

part,  the  lower  the  pitch,  and  per  contra. 
The  Ch'eater  the   Tension  of  the  Inclosing  Wall, 

the  higher  the  pitch,  and  per  contra. 
Proocimity  of  Solid  Bodies  elevates  the  pitch. 
The  Larger  the  Ojiening  in  a  cavity,  the  higher 
the  pitch. 
The  Varieties  of  Percussion  Sbunds. 

JVOB3IAL      BULMONABY      OB      VESICULAB 
BESONANCE  or  lung  sound. 
LOCATION,   over   those   parts    of  the  healthy  lung 
which  do  not  overlap  the  heart,  liver,  or  spleen, 
and  which  are  not  covered  by  the  scapulae  {vide  the 
landmarks).    The  resonance  obtained  over  the  lung 
w^hich  overlaps  these  organs,  while  normal  vesicular, 
is   relatively   less    resonant,    and   hence   properly 
termed   dulness.     Resonance   is   less   intense  and 
higher  in  pitch  over  the  right  apex  than  over  the  left. 
CAUSE  of  the  normal  vesicular  resonance ;  it  is  prob- 
ably due  to  the  combined  vibration  of  the  walls  of 
the  chest,  alveoli,  and  bronchi  and  the  air  con- 
tained within  them,  the  resonance  of  the  deeper 
parts  being  modified  by  the  thickness  of  the  fleshy 
parts  and  by  the  elasticity  of  the  bony  elements. 
CHARACTER  of  normal  vesicular  resonance. 
Quality,  soft,  clear,  full,  resonant,  vesicular. 
Pitch,  low. 
Intensity,  great. 
Duration,  long. 
VARIATIONS  IN  CHARACTER. 
In  the  Same  Individual , 

In  a  Griven  Location  vesicular  resonance  varies 

with  the  degree  of  respiratory  expansion. 
In  Different  Locations  it  varies  according  to 
the  size  or  amount  of  lung  under  the  part  and, 
the  thickness  of  the  chest- wall. 


METHODS  OF  PHYSICAL  DIAGNOSIS  65 

III  Different  Indirlduals  it  varies  according  to 
the  same  factors. 
EXAGGERATED  rULMONARY  MESONANCE, 

LOCATION. 

Norniul,  over  both  lungs  in  children. 
Abnomial, 

Over  both  Lung-s   in  marked  anaemia,  in  em- 
physema (the  resonance  present  in  this  disease 
has  also  been  termed  by  Flint  vesiculo-tym- 
panitic). 
Over  One  Lung"  when  the  other  is  partially  or 
wholly   crippled   by   consolidation,   compres- 
sion, etc. 
Over  Sound  Parts  of  a  crippled  lung. 
CAUSE,  the  lung  is  over-distended  with  air,  either 
functionally,   or   from    organic  trouble  as  in  em- 
physema. 
CHARACTER  :  this  is  like  that  of  vesicular  resonance, 
except  for  increase  of  intensity  and  duration  and 
slightly  lower  pitch. 
VARIATIONS     IN     CHARACTER     accord    with     the 
amount  of  air  in  the  part,  within  reasonable  limits. 
BOWE  RESONANCE. 

LOCATION,  over  the  sternum  and  clavicle,  and  to  a 

slight  extent  over  the  ribs. 
CHARACTER. 

Quality,  non-tympanitic,  resonant,  ringing. 
Pitch,  higher  than  that  of  vesicular  resonance. 
Intensity,  less  than  that  of  vesicular  resonance. 
Duration,  shorter  than  that  of  vesicular  resonance. 
DULNESS,  diminished  resonance.     It  includes  vesic- 
ular and  tympanitic  dulness. 
LOCATION. 

Normal  Vesicular  Dulness  is  obtained  where  the 
lung  overlaps  the  heart,  liver,  and  spleen  and 
underlies  the  scapulae.     Normal  tympanitic  dul- 


PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

ness  is  found  over  the  lower  part  of  the  liver, 
heartj  and  spleen  when  the  stomach  and  colon 
are  distended  with  gas. 
Abnormal  Vesicular  Dulness  is  obtained  over 
Thickening'  of   the   Chest-wall  from  oedema, 

tumor,  or  inflammatory  swelling. 
Interposition,  between  the  lung  and  chest-wall, 
of  solids  or  fluids;  a  moderately  thick  layer 
of  inflammatory  lymph  on  the  pleural  surface  ; 
a  moderate  amount  of  pleuritic  effusion,  in- 
flammatory or  non-inflammatory ;  extra-pul- 
monary tumors  of  small  size. 
Consolidation  of  the  Lung",  moderate  in  amount: 
pneumonia,  tuberculosis,  syphilis,  new  growths, 
oedema,    pulmonary    hemorrhage,    collapse    of 
lung. 
CAUSE,  less  air  or  relatively  more  solids  beneath  the 

part  than  in  normal  lung. 
CHARACTER. 

Quality,  harder,  emptier,  less  clear,  less  vesicular 

than  normal  pulmonary  vesicular  resonance. 
Pitch,  higher. 
Intensity,  less. 
Duration,  shorter. 
VARIATIONS,   in  character  in  different  individuals 
and  in  different  localities,  accord  Avith  the  relative 
amount  of  air  or  solids,  approaching  the  character 
of  pure  pulmonary  resonance  on  the  one  hand  and 
flatness  upon  the  other. 
FLATNESS. 
LOCATION. 

Normal,  over  those  organs  or  parts  containing  no 
air,  hence  over  that  portion  of  the  heart,  liver, 
spleen,  and  kidneys  uncovered  by  lung. 
Abnormal,  over  the  chest  when  there  is  an  exag- 
geration of  any  of  those  morbid  conditions  which 


METHODS  OF  PHYSICAL  DIAGNOSIS.  67 

in  a  slight  degree  produce  dulness  :  pleurisy  with 
effusion,  emphysema,  hydro-thorax,  etc. 
CAUSE,  entire  absence  of  air  or  gas  in  and  for  some 
distance  beneath  the  organ  under  the  part  percussed. 
CHARACTER. 

Qualitij,  hard,  empty,  muffled,  non-resonant,  the 

^^  thigh  sound." 
Pitchf  very  high,  highest  of  all  percussion  notes. 
Duration,  very  short. 
NO    VARIATIONS    OF    ITS  CHARACTER,  as   such, 
occur  ;  it  may  be  modified  by  tympanitic  resonance, 
where  hollow  gas-containiilg  organs  like  the  stom- 
ach or  colon  underlie  a  solid  organ  like  the  liver ; 
it  is  then  termed  tympanitic  dulness,  really  a  modi- 
fication of  tympany. 
TYMPANITIC  RESONANCE  or  tympany. 
LOCATION. 

Normal,  where  the  stomach  or  colon,  distended 
with  gas,  underlies  the  infra-mammary,  infra- 
axillary,  and  infra-scapular  regions,  and  some- 
times over  the  lower  part  of  the  mammary  and 
inferior  sternal  regions ;  also  over  the  trachea. 
Ahnomial. 

Over  a  part  of  the  chest  when  Gas  is  present 

in  the  Pleural  Sac,  pneumo-thorax. 
Over  a  Pulmonary  Air-containing  Cavity  of 

large  size,  phthisis,  abscess. 
Complete  Solidification  of  a  Part  of  the  upper 
lobe  of  the  lung,  tympany  being  obtained  from 
the  trachea  beneath  (''  tracheal  tone  "  of  Wil- 
liams), second  stage  of  pneumonia,  phthisis. 
Bronchiectasis  with  surrounding  solidification, 

interstitial  pneumonia. 
Conduction  of  Stomach  Resonance  high  up 
on  the  left  side,  when  the  lower  lobe  of  the 
left  lung  is  solidified. 


68  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

CAUSE,  percussion  over  a  hollow  gas-containing  or- 
gan or  cavity,  the  walls  of  which  are  more  or  less 
thin  and  tense. 
CHARACTER. 

Qualittj,    non-vesicular,     resonant,    ringing,    but 

harder  than  vesicular  resonance. 
Pitchy  higher  than  vesicular  resonance,  variable. 
Intensitij  and  duration  variable. 
VARIETIES  OF  TYMPANY. 

Closed  Ti/mjMiny  is  the  sound  obtained  by  percus- 
sion over  a  cavity  filled  with  gas,  and  not  com- 
municating -  freely  by  an  opening  with  the  ex- 
ternal air — e.  g.,  the  stomach  and  colon.     It  is 
obtained  also  in  some  cases  of  pneumothorax. 
O^jen  Tympany  includes  amphoric  and  cracked- 
metal  resonance. 
Amphoric  Resonance  is  obtained  over  a  cavity 
with  a  large  opening,  as  in  percussion  of  the 
cheeks  Avith  the  mouth  open. 
Location  . 

Normal  over   the   trachea,    and   sometimes 
over  the  upper  part  of  the  chest  in  chil- 
dren. 
Abnormal^  abscess  or  tubercular  cavity  com- 
municating with  a  large  bronchus. 
Cause,  percussion  over  a  moderate  sized  gas- 
containing  cavity  with  rigid,  non-collapsing 
walls  and  free  communication  by  a  large 
opening ;  tlie  examiner's  ear  or  the  mouth 
of    the    stethoscope    should    be    near   the 
patient's  open  mouth. 
Character,  its  quality  is  tympanitic  but  pe- 
culiarly ringing  and  hollow  like  the  sound 
produced  by  blowing  across  the  mouth  of  a 
bottle  ;  its  pitch  is  higher  than  vesicular  res- 
onance, but  varies  with  the  size  of  the  cavity 


METHODS  OF  PHYSICAL  DIAGNOSIS.  69 

and  of  the  opening,  and  the  condition  of  the 
adjacent  lung.      Its  intensity  and  duration 
are  variable. 
Change  in  the   Character  of  am])horic 
resonance. 
Wintrich\s  change  of  aound  only  occurs  over 
a  cavity  which  freely  communicates  with 
a  bronchus  ;  a  louder,  more  amphoric,  and 
higher-pitched   note   is    produced  over  a 
cavity  when  the  mouth  is  open,  especially 
with   the  tongue  protruding.     The  note 
wdth  the  mouth  closed  may  be  dull  but 
slightly  tympanitic. 
Williams''  tracheal  tone,  or  change  of  sounds 
so  called,  is  the  tympanitic  note  obtained 
by  percussion  over  the  trachea,  its  change 
in  character  being  similar  to  that  in  Wint- 
rich's  change  of  sound. 
Interrupted  Wintrich\s  change  of  sound  (Ger- 
hardt,    Moritz).     This    differs    from    the 
former  in  that  the  change  is  marked  in 
some  positions  of  the  body,  in  others  in- 
distinct or  absent  owing  to  the  closure  of 
the  opening  by  the  secretions  wdthin  the 
cavity. 
Gerhardfs  change  of  sound.    A  tympanitic 
sound,  whether  open  or  closed,  may  change 
in  pitch  with  change  in  posture.     This 
may  be  due  to  the  change  in  the  tension 
of  the  chest-wall  and  that  of  the  cavity, 
and   to  the  change  in  location  of  fluids 
within  the  cavity. 
Friedreich's  J  or  the   respiratory  change  of 
sound.    A  tympanitic  note  over  the  lung, 
or  over  a  cavity  within  it,  is  higher  in 
pitch  at  the  end  of  deep  inspiration  than 


70  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

in  expiration,  due  probably  to  the  higher 
tension. 
Cracked-metal  Resonance  is  a  form  of  open 
tympany,  and  may  be  imitated  by  striking 
upon  the  knee  with  the  hands  loosely  clasped 
palm  to  palm. 
Location  and  Cause. 
Normal.  \ 

1.  If  the  chest  be  covered  with  much 
hair,  under  percussion. 

2.  If  the  pleximeter  be  loosely  applied. 

3.  Sometimes  it  is  obtained  over  the  upper 
part  of  the  chest  of  children,  especially 
when  crying. 

4.  Sometimes  in  adults  when  singing  a 
prolonged  note. 

Abnormal. 

1.  Over  some  air-containing  pulmonary 
cavities  communicating  with  a  bronchus 
by  a  small  opening ;  percussion  should 
be  firm,  and  during  expiration,  the 
patient's  mouth  being  open. 

2.  Occasionally  in  pleurisy,  over  the  lung 
above  the  effusion ;  sometimes  in  the 
engorgement  stage  of  pneumonia. 

3.  When  an  opening  exists  through  the 
chest-wall  into  the  pleural  sac. 

AUSCULTATION. 

METHODS  of  auscultation. 
Immediate  or  direct. 
Mediate  or  indirect. 

INSTRUMENTS  of  mediate  auscultation,  the  stethoscope. 
Varieties. 

UNIA  UBALf  hollow  and  solid. 


METHODS  OF  PHY  SIC  AL  DIAGNOSIS  71 

BIN AUR A h,Km^\i^^y  Camman's,  Dennison's,  Alli- 
son's differential,  Corwin's  multiplex. 
Objections  to  the  stethoscope. 

IT  HAS  A  SrECIAL  RING  or  roaring  sound  like  a 

shell. 
OFTEN  rOORLY  MADE, 
FRIGHTENS  CHILDREN. 
NOT  ALWAYS  AT  HAND. 
Advantages  of  the  stethoscope. 

SHUTS  OUT  OUTSIDE  SOUNDS. 
CONCENTRATES  and  circumscribes  sounds. 
INTENSIFIES  sounds. 

CERTAIN  PARTS  OF  THE  CHEST  ARE  INAC- 
CESSIBLE to  the  unaided  ear. 
IT  IS  SOMETIMES  INDELICATE  to  apply  the 

ear  directly  to  the  chest. 
IT  IS  SOMETIMES    UNFLEASANT  and  may  be 
DANGEROUS  to  apply  the  ear  to  the  chest. 
RULES  for  auscultation. 

The  Patient  should  have  regard  to 

SY3IMETRY,  immobility,  and  ease  of  position. 
THE  CHEST  SHO  ULD  BE  BARE  for  mediate  aus- 
cultation, and  should  have  a  single  layer  of  thin  soft 
covering  for  immediate  auscultation. 
Tine  Examiner  should  have 

THE  HEAD  on  a  plane  higher  than  the  body  to  pre- 
vent congestion  of  the  auditory  apparatus  ; 
THE  A  TTENTION  concentrated  upon  one  sound  or 
set  of  sounds  at  a  time. 
The  Instruments. 

THE  EAR-FIECE  should  fit  the  external  meatus  ac- 
curately and  point  in  the  same  direction  as  the  canal, 
downward  and  forward. 
THE  TUBES  should  be,  in  lumen,  the  size  of  the  ex- 
ternal auditory  canal ;  it  is  of  no  advantage  to  have 
them  larger. 


72  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

THE  L AUGER  CHEST-JPIECE  should  not  exceed 
one  and  one-fourth  inch  in  diameter  at  the  distal  end. 
It  is  designed  for  the  lung  sounds. 

THE  SMALLER  CHEST-PTECE  is  especially  de- 
signed for  the  sounds  of  the  heart  and  vessels.  But 
it  answers  very  well  for  auscultation  of  the  lungs. 

THE  ENTIRE  LENGTH  of  the  instrument  from  ear- 
piece to  chest-piece  should  not  exceed  about  twenty-two 
inches  {vide  cut  of  simple  compact  stethoscope  which 
the  author  has  found  a  most  satisfactory  combination). 
The  Act  of  auscultation. 

THE  R003I  should  be  quiet. 

THE  EAR  OF  THE  STETHOSCOPE  should  be 
firmly  applied  to  the  chest. 

THERE  SHOULH  BE  NO  FRICTION  between 
parts  of  the  instrument ;  between  the  chest  and  the 
instrument ;  between  the  hand  and  the  instrument ; 
between  the  hand  and  the  chest ;  between  the  hand 
and  the  clothing ;  between  the  chest  and  the  clothing. 

CORRESPONDING  PARTS  OF  THE  CHEST 
should  be  compared,  and  in  like  stages  of  respiration. 

THE  ENTIRE  CHEST  should  be  examined. 

SOUNDS  HEARD  upon  auscultation. 
The  Elements  of  sound. 
QUALITY,         ^ 
PITCH,  I  . 

DURATION      I  percussion  sounds. 

INTENSITY,    J 

RHYTHM  is  the  relation  of  sounds  to  each  other,  as 
that  of  inspiration  to  expiration,  or  the  relation  of  the 
first  and  second  sounds  of  the  heart. 
Varieties  of  Sounds  upon  auscultation. 
PULMONARY  sounds. 

RESPIRATORY  sounds  vary  in  kind,  intensity,  and 
rhythm. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  73 

Kinds  or  Veirieties  of  liespiratoi'y  Si>i(nd. 

Normal  Vesicular  Breathing  (persons  should 
breathe  more  forcibly  than  usual,  but  with 
the  same  rhythm). 
Locality  :  it  is  heard  over  the  i)arenchyma 
of  the  lung  away  from  the  main  bronchi ; 
best  in  the  infra-scapular  regions. 
Cause  of  the  vesicular  sound  (opinic>n  varies). 
It  may  he  produced  at  the  glott'iH,  and  mod- 
ified by  conduction  through  the  spongy 
tissue  of  the  lung. 
It  may  be  due  to  the  entrance  of  air  into  the 

alveoli  during  dilatation. 
It  may  he  due  to  the  vihration  of  the  lung 
substance  from  increased  tension  in  in- 
spiration   and    the    reverse    in    expira- 
tion. 
Character. 

Inspiratory  sound. 

Quality,  breezy,  rustling,  soft,  vesicular. 
Pitch,  low  compared  with  that  of  laryn- 
geal breathing. 
Intensity,  variable. 

Duration,  coincident  with  the  inspiratory 
act. 
Expiratory  sound. 

Quality,  like  the  inspiratory  but  less  vesic- 
ular. 
Pitch,  lower  than  that  of  tlie  inspiratory 

sound. 
Intensity,  variable ;  the  sound  may  not 

be  appreciable  but  is  generally  so. 
Duration,  much  shorter  than  the  expira- 
tory act. 
Rhythm  :  the  ratio  of  the  inspiratory  to 
the   expiratory   sound   is   about   three 


74  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

to  one^  there   being   a  sliglit   interval 
between  them. 
Variation  in  character  largely  depends  upon 
the  nearness  of  the  point  of  auscultation 
to  the  large  bronchi. 
Bronchial  Breathing*. 
Locality  and  Cause. 

Normal,  heard  over  the  trachea. 
Abnormal  (as  a  sign  of  disease),  heard  over 
consolidated  lung,  the  main  bronchi  lead- 
ing to  which  are  patulous,  consolidated 
lung  being  a  better  medium  of  conduction 
of  the  sound  from  the  larynx.   It  is  heard 
in  pneumonia  and  phthisis. 
Character,  it  is  substantially  like  that  of 
tracheal  breathing,  though  slightly  less  in- 
tense. 
Laryngeal  and  Tracheal  Breathing"  differ  from 
each  other  but  little. 
Locality,  heard  over  the  larynx  and  trachea. 
Character. 

Inspiratory  sound. 

Quality,  tubular,  blowing,  but  changing 
in  harshness  with  the  force  of  the  act. 
Pitch,  higher  than  that  of  the  inspiratory 
sound  of  normal  vesicular  breathing, 
and  varying  in  pitch  with  the  force  of 
the  act. 
Intensity,  great  but  variable. 
Duration,  a  little  shorter  than  the  inspira- 
tory act. 
Expiratory  sound. 

Quality,  very  similar  to  that  of  inspiration. 
Pitch,  higher  than  that  of  inspiration. 
Intensity,  greater  than  that  of  vesicular 
breathing. 


METHODS  OF  PHYSICAL  DIAGSOSIS.  1-) 

Duration,  longer  than  that  of  the  expira- 
tory sound  of  vesicular  breathing. 
Rhythm  :  the  expiratory  sound  is  as  long 
as  the  inspiratory,  and  a  short  interval 
exists  between  them. 
Cavernous  Breathing-. 

Locality  (it  is  an   abnormal    sound)  heard 

over  some  pulmonary  cavities. 
Cause,  empty  pulmonary  cavity  with  easily 
collapsing  and  expanding  walls  in  ex])ira- 
tion  and  inspiration. 
Character. 

Inspiratory  sound. 

Quality,    soft,   blowing,  or   puffing,  but 

neither  vesicular  nor  tubular. 
Pitch,  low. 

Intensity,  variable,  but  usually  slight. 
Duration,  variable. 
Expiratory  sound. 

Quality,  like  that  of  the  inspiratory  sound. 
Pitch,  lower  than  that  of  the  inspiratory 

sound. 
Intensity,  variable,  but  usually  slight. 
Rhythm  :   the  expiratory  sound  is  about 
the  same  length  as  the  inspiratory. 
Broncho-cavernous  Breathing*. 

Locality  and  Cause,  cavity  surrounded  by 
solidified  lung,  as  is  found  sometimes  in  the 
late  stage  of  tuberculosis,  abscess,  or  gan- 
grene. 
Character,  both   cavernous   and  bronchial 

elements  are  heard  together. 
Varieties,  metamorphosing  breathing ;  here 
the  inspiratory  sound  is  bronchial  at  first, 
but  suddenly  becomes  cavernous. 
Vesiculo-cavernous. 


76  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Locality  and  Cause,  cavity  covered  by  more 

or  less  healthy  lung. 
Character,  as  indicated  by  its  name. 
Amphoric  Breathing. 

Locality,  over  a  large  cavity  with  relatively 
rigid  walls  and  with  a  large  opening,  as  may 
be  obtained  in  tuberculosis  and  occasionally 
in  pneumothorax.  ^ 
Cause,  the  peculiar  vibration  of  air  in  its 
passage  in  and  out  of,  or  across  the  mouth 
of  a  flask-like  cavity. 
Character. 

Inspiratory  sound  most  distinct. 

Quality,  musical,  hollow,  metallic,  harder 

than  that  of  cavernous  breathing. 
Pitch  of  expiratory  sound  lower  than  that 

of  bronchial  breathing. 
Intensity,  usually  greater  than   that   of 

cavernous  breathing. 
Rhythm  :  amphoric  breathing  is  usually 
heard  best  in  inspiration. 
Intensity  of  Hespiratory  Sotitids. 

Bxag-g-erated,     Supplementary,    or     Puerile 
Breathing. 
Locality. 

Normal  in  childhood,  the  chest-walls  being 

thin  and  elastic. 

Abnormal,  over  one  lung  when  the  other  is 

crippled    by    consolidation,    obstruction, 

etc. ;  over  healthy  parts  of  a  crippled  lung. 

Cause,  the  lung  is  performing  more  than  its 

usual  function. 
Cpiaracter,  like   that  of   normal  vesicular 
breathing,' except  of  greater  intensity;  both 
inspiratory  and  expiratory  sounds  are  louder 
and  longer  than  usual. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  11 

Feeble  Respiration. 

LOCA  LIT  Y. 

Normal. 

Ov'er  thick  chest-walls,  as  in  muscular  or 
fat  persons ;  over  the  female  mammae 
and  over  the  scapulae. 

At  a  distance  from  the  large  bronchi,  over 
the  lower  part  of  the  chest,  especially 
in  women. 

In  superficial  breathing. 

The  vesicular  murmur  is  normally   less 
intense  on  the  right  than  on  the  left 
side. 
Abnormal  from 

Imperfect  transmission,  due  to  oedema  or 
vswelling  of  the  chest-walls ;  air,  fluid, 
or  inflammatory  lymph  in  the  pleural 
sac. 

Loss  of  elasticity  of  the  lung,  emphysema. 

Partial  blocking  of  the  air-cells  with  blood 
or  serum,  as  in  pulmonary  oedema. 

Consolidation  of  lung  with  filling  up  of 
the  bronchi. 

Obstruction  of  the  larynx,  trachea,  or 
bronchi  from  a  collection  of  pus,  mucus, 
blood,  or  fibrin  ;  foreign  body ;  thick- 
ening of  the  mucous  membrane ;  pres- 
sure of  tumors. 

Constriction  of  the  tubes  from  muscular 
contraction,  asthma,  bronchiolitis. 

Deficient  action  of  the  respiratory  muscles. 
Mechanical  obstruction,  as  in  tympany, 

ascites,  abdominal  tumors. 
Pain,  as  in  pleurisy,  peritonitis,  pleuro- 
dynia, neuralgia. 
Paralysis  of  the  diaphragm. 


78  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Suppressed  Respiratory  Sound ;  entire  absence 
of  respiratory  sounds. 
Locality  and  Cause,  an  exaggeration  of  the 
conditions  which  produce  feeble  respiration  : 
pneumo-thorax,  hydro-thorax,  occlusion  of 
the  larger  air-passages. 
Mhythni  of  Respiratory  Sounds. 

Interrupted,  Jerking,  Wavy  or  Cog-Wheel 
Respiration. 
Locality. 

Normal,  in  nervous  persons,  agitated  by  ex- 
amination ;  here  it  is  apt  to  be  heard  more 
or  less  over  the  whole  chest,  but  it  may 
be  localized ;  sometimes  it  is  heard  in 
healthy  persons  from  no  apparent  cause. 
Abnormal,  it  may  accompany  : 

Pain,  as  in  pleurisy,  pleurodynia,  inter- 
costal neuralgia ;  it  is  generally  heard 
over  the  whole  chest. 
Phthisis,  here  it  may  be  an  early  sign, 
localized  over  the  affected  apex. 
Cause  of  cog-wheel  breathing  :  in  some  cases 
(pain  and  nervousness)  it  may  be  due  to  the 
irregular  and  undecided  manner  of  respira- 
tion, in  others  (phthisis)  it  is  probably  caused 
by  the  break  or  delays  in  the  passage  of  air 
through  the  affected  bronchioles. 
Character  :  either  the  inspiratory  or  expira- 
tory sound,   or  both,  may  be  broken  into 
several  parts,  or  may  be  characterized  by 
successive  variations  in  intensity ;   usually 
it  is  most  marked  in  inspiration. 
Interval  between  Inspiration  and  Expiration 
may  be  more  or  less  prolonged. 
In  emphyse]\ia,  owing  to  a  deferred  expira- 
tory soiuid. 


METHODS  OF  PHYSICAL  DIAGNOSIS  79 

In  consolidation  of  the  lung  owing  to  short- 
ening of  the  inspiratory  sound. 
Shortened  Inspiratory  Sound. 

Locality  (where  and  w  hen  licard)  and  Cause. 
In  emphysema  it  is  due  to  the  beginning  of 
the  respiratory  aet  before  the  beginning 
of  the  sound. 
In  consolidation  (bronchial  breathing)  it  is 
due  to  the  ending  of  the  inspiratory  sound 
before  the  ending  of  the  inspiratory  act. 
Chakacter. 

When  due  to  emphysema. 
Quality,  vesicular. 
Pitch,  comparatively  low. 
When  due  to  consolidation. 
Quality,  tubular. 
Pitch,  high. 
Prolonged  Expiratory  Sound. 
Locality. 

Normal,  over  the  right  apex ;  sometimes  pro- 
longed expiratory  sound  over  the  left  apex 
in  slightly  less  degree ;  over  the  larynx, 
trachea,  and  bronchi  (vide  the  landmarks). 
Abnormal,  over  consolidated  lung;  over  a 
cavity ;    over   emphysematous    lung ;    in 
asthma  ;  in  case  of  certain  valve-like  ob- 
stacles in  the  air-passages. 
Cause  :   difficult  and  prolonged   exit   of  air 
from  the  lungs — e.  g.,  in  emphysema,  owing 
to  loss  of  elasticity  of  the  lung ;  in  asthma, 
owing  to  spasm  of  the  bronchial  muscles. 
Character. 

When  due  to  solidification  of  the  lung. 
Quality,  tubular. 
Pitch,  high. 
When  due  to  a  cavity. 


80  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Quality,  blowing,  cavernous  or  amphoric. 
Pitch,  low. 
When  due  to  emphysema. 
Quality,  vesicular. 
Pitch,  low. 
When  due  to  asthma. 
Both  quality  and  pitch  are  obscured  by 
dry  rales. 
VOCAL  SOUNDS. 

Eletne^its  of  Sound:  these  are  like  those  consid- 
ered in  respiration  and  percussion,  though  not 
all  of  them  are  so  significant  in  the  consideration 
of  vocal  sound. 
Varieties  of  Vocal  Sound, 
Normal  (Vesicular)  Vocal  Resonance. 
Locality,  it  is  heard 

Over  the  lung  at  a  distance  fi^om  the  trachea 

and  bronchi  while  the  person  is  speaking. 

In  adult  males  it  is  generally  heard  over  the 

entire  lung. 
In  ivomen  and  ehildren  it  is  heard  over  the 
upper  part  of  the  chest,  and  but  indis- 
tinctly over  the  lower  part. 
Cause  :  it  is  due  to  the  transmission  of  the 
voice  through  the  parenchyma  of  the  lung 
and  the  chest- wall. 
Character. 

Quality^  diffused,  muffled,  buzzing,  seeming 
to  come  from  the  deep  parts  of  the  lung 
(articulation  not  transmitted). 
Pitch,  varies  with  the  pitch  of  the  voice. 
Intensity,  greater  over  the  right  apex  than 
over  the  left,  especially  in  the  infra-clav- 
icular Region. 
Variations  from  the  normal  are  chiefly  in 
intensity. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  81 

Diminished  vocal  resonance. 

Locality  and  cause  :  it  is  the  result  largely 
of  those  conditions  ^vhich  cause  feeble 
respiratory  sounds. 
Exaggerated  vocal  resonance. 

Locality  :  it  is  heard  over  moderately  con- 
solidated lung ;  pneumonia,  phthisis,  etc. 
Cause,  consolidated  lung  is  a  better  me- 
dium for  transmitting  sound  from  the 
larynx  than  is  ordinary  lung  tissue. 
Character  :  it  differs  from  normal  vocal 
resonance  simply  in  being  more  intense, 
seeming  to  come  from  a  point  not  far 
distant  from  the  surface.     It  is  usually 
associated  with  broncho- vesicular  respi- 
ration. 
Bronchophony  or  Bronchial  Voice. 
Locality. 

Normal,  heard  over  the  main  bronchi. 
Abnormal,  heard. 

Over  consolidated  lung  as  in  the  second 
stage  of  pneumonia,  phthisis  ;  above  the 
level  of  the  fluid  in  pleuritic  effusion. 
Over  a  vomica  with  firm  walls  (some- 
times), surrounded  by  consolidation. 
Cause,  consolidated  lung  a  better  medium  of 

transmission. 
Character.  It  is  more  concentrated  than  nor- 
mal vocal  resonance  and  exaggerated  vocal 
resonance,  seeming  to  come  from  a  point 
near  the  ear,  immediately  under  the  steth- 
oscope (no  distinct  articulation).  It  is  usually 
associated  with  bronchial  breathing,  though 
not  necessarily,  li^  pitch  varies,  and  its  in- 
tensity also,  though  usually  increased  above 
that  of  normal  resonance. 


82  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Varieties  of  Bronchophony. 
jEgopho7iy  (goat  voice). 

Locality^  over  consolidated  lung,  covered 
by  a  thin  layer  of  fluid  in  the  pleural 
cavity,  as   in    pleuro-pneumonia  with 
slight  pleuritic  effusion. 
Character,  it  is  like  that  of  bronchophony, 
except  that  it  i$  of  less  intensity  and 
has  a  tremulous  sound,  seeming  to  come 
from  a  considerable  depth. 
Pectoriloquy  (speaking  through  the  chest). 
Locality  and  cause.     It  is  heard 

1.  Over    consolidated    lung,    phthisis, 

pneumonia. 
(a)  Quality,  clanging,  metallic. 
{h)  Pitch,  high. 

2.  Over  a  cavity  with  smooth  walls  and 

a   large    opening,    abscess,   bron- 
chiectasis, etc. 
(a)  Quality,  soft. 
(6)  Pitch,  low. 
Character,  it  is  like  that  of  bronchophony 
with  the  addition  of  distinct  articula- 
tion in  the  transmitted  voice. 
Amphoric  Voice. 

Locality,  over  pneumo-thorax  or  pulmonary 

cavity  Avith  a  free  opening. 
Character. 

Quality,  hollow,  musical. 
Pitch   and  Intensity,   variable.     It   is   fre- 
quently associated  with  amphoric  respira- 
tion and  resonance. 
WHISPERING  SOUNDS. 

Normal  Whispering  Mesonance. 
Exaggerated  Whispering  Mesonance, 
WJiispering  Bronchophony, 


METHODS  OF  PHYSICAL  DIAGNOSIS.  83 

Cavernous  Whisper. 
Whispering  Pectoi'iloquy. 
Awtphoric  Whisper, 

These  whispering  sounds  correspond  largely  in 
locality,  cause  and  character  to  the  vocal  sounds, 
the  sound  of  phonation  being  substituted  by  that 
of  aspiration. 
TUSSIVE  OR  COUGH  SOUNDS.  Cough  though  a 
symptom  is  a  sign  of  importance. 
Definition,  A  deep  inspiration  is  followed  by 
closure  of  the  glottis,  contraction  of  the  mus- 
cles of  expiration,  rise  of  tension  within  the 
pulmonary  air-passages,  and  sudden  opening  of 
the  glottis  with  violent  explosive  escape  of  the 
compressed  air  and  fibration  of  the  vocal  cords. 
delation  to  Auscultation,  Much  the  same  laAVS 
govern  the  sounds  produced  by  coughing  as 
apply  to  vocal  sounds  in  auscultation  of  the 
chest. 

Coug-h   may  Remove    Temporary  Obstacles 
from   the  air-passages,  thereby  changing    or 
destroying  sounds. 
It  Necessitates  Subsequent  Deep  Inspiration 
with  consequent  distention  of  the  air- vesicles. 
Varieties  of  Cough.     It  is  dry  or  moist  according 
to  the  amount  and  character  of  the  accompany- 
ing secretion. 

Laryngeal  Cough,  hacking,  often  spasmodic, 
and  due  to  laryngitis,  local  irritation^  or  to 
reflex  nervous  trouble. 
Bronchial  Coug-h,  dry  or  tight,  quick,  harsh, 
and  brassy.  Tjoose,  more  or  less  rattling, 
owing  to  secretion  within  the  tubes.  It  is 
frequently  accompanied  by  pain  along  the 
attachments  of  the  diaphragm,  and  more  or 
less  soreness  under  the  sternum.     Bronchitis. 


84  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Cavernous  Cough  has  a  hollow  quality,  and  is 
usually  intense  and  accompanied  by  gurgling 
sounds. 
Amphoric  Cough  is  ringing,  with  the  peculiar 
resonance  heard  in  blowing  across  the  neck  of 
a  bottle. 

The  terms  cavernous  and  amphoric  cough 
refer  to  sounds  he^rd  upon  auscultation 
in  certain  cases  where  cavities  open  into 
large  bronchi. 
Causes  of  Cough.     It  may  be 
Voluntary,  or  may  be 
Involuntary,  due  to  stimulation  of  the 

Nerve  centre  in  the  floor  of  the  fourth  ven- 
tricle. 
Eeflex. 

Nerve-trunhs, 

Vagus  or  superior  laryngeal  nerves. 
Peripheral. 

Direct  stimulation   of  the  mucous  mem- 
brane of  the  air-passages  by  irritat- 
ing particles,  cold  air,  etc.      Espe- 
cially the  surface  of  the 
Soft  palate  and  pharynx.     The 
Larynx  is  the  most  sensitive  part  of  the 

air-passages. 
Trachea  and  bronchi :  the  most  sensi- 
tive part  is  at  the  bifurcation  of  the 
trachea. 
Indirect  stimulation. 

Irritation  of  the  pleura  (the  costal  layer) 

as  in  pleurisy. 
Irritation  of  the  auditory  meatus. 
Decayed  teeth. 
Irritation  of  the  post  nares. 
Irritation  of  the  skin  by  cold  draughts. 


METHODS  OF  PHYSICAL  DIAGNOSIS  85 

Derangement  of  the  domach  possibly  a 
ciiuse  of  (tough. 
ADVENTITIOUS  SOUNDS. 

Moist  Rales. 

Large,  coarse,  or  mucous  rales. 

Locality^  where  produced  :  large  and  middle- 
sized  tubes  ;  "  death  rattle  "  heard  in  the 
trachea. 
Cause,  air  bubbling  through  fluid,  whether 

mucus,  blood,  or  pus. 
Character. 

Quality,  bubbling,  moist. 
Pitch,  usually  low  but  variable. 
Intensity,  variable. 

Duration,  they  may  be  removed  by  cough- 
ing or  deep  inspiration. 
Rhythm,  they  may  accompany  inspiration, 
expiration,  or  both. 
Condition,  acute  and  chronic  bronchitis,  pro- 
fuse pulmonary  hemorrhage,  etc. 
Small,  fine,  mucous,  or  subcrepitant  rAles. 
Locality,  small  tubes. 
Cause,  air  bubbling  through  fluid. 
Character. 
Quality,  moist,  fine,  bubbling,  or  crack- 
ling or  sticky  (mixed  in  size). 
Pitch,  varying  with  size  of  tube  and  con- 
dition of  surrounding  lung. 
Intensity,  variable. 
Duration,  they  may  be  removed  by  deep 

inspiration  or  cough. 
Rhythm,  they  may  accompany  either  or 
both  acts  of  respiration. 
Condition,  capillary  bronchitis,  third  stage 
of  tuberculosis,  lobular  pneumonia,  pul- 


86  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

monary   congestion    and   oedema,    severe 
hemorrhage,  chronic  bronchitis,  etc. 
Dry  Rales. 

Sonorous  Rales. 
Locality,  large  tubes. 

Cause,  narrowing  of  the  lumen  of  the 
bronchi,  from  viscid  mucus  adhering  to 
their  wall ;  swelling  of  the  mucous  mem- 
brane ;  spasm  of  the  annular  bronchial 
muscles ;  fibroid  contractions  ;  pressure 
upon  the  bronchi  by  an  aneurysm  or  other 
tumors  or  swellings. 
Character. 

Quality,  snoring. 
Pitch,  low. 

Intensity,  variable,  usually  very  loud. 
Duration,  they  are  usually  not  removable 
by  cough  or  deep  inspiration,  except 
when  due  to  viscid  mucus. 
Rhythm,  they  may  accompany  either  or 
both  acts  of  respiration. 
Conditions,    asthma,    bronchitis,   and   other 
more  rare  conditions  causing  narrowing 
of  the  tubes. 
Sibilant  RIles. 
Locality,  small  tubes. 
Cause,  same  as  that  of  sonorous  rales. 
Character. 
Quality,  whistling,  hissing,  creaking. 
Pitch,  high. 

Intensity,  less  than  sonorous,  but  variable. 
Duration,  they  may  be  removed  by  cough 

or  deep  inspiration. 
Rhythm',  they  may  accompany  either  or 
both  acts  of  respiration. 
Conditions,  asthma  and  bronchitis. 


METHODS  OP  PIIYStCAL  DIAGNOSIS.  87 

Crepitant  Kales. 

Locality^  they  are  produced  in  the  ultimate 

air-vesicles. 
Cause  (probably),  sudden  separation  of  the 
walls  of  collapsed  air-vesicles,  adhering 
more  or  less,  from  the  presence  of  fibrinous 
exudate  upon  their  surfaces. 
Charader. 
Quality,  like  the  crackling  of  salt  thrown 
upon  the  fire,  dry,  very  fine,  numerous, 
and  uniform  in  size,  as  compared  with 
subcrepitant  rales,  Avhich  are  coarser, 
bubbling,  moist,  fewer  in  number,  and 
of  different  sizes. 
Pitch,  high. 
Intensity,  variable. 

Duration,  they  are  not  disturbed  by  cough. 
Rhythm,  they  are  never  heard  in  expira- 
tion, always  in  inspiration,  usually  at 
its  end. 
Condition,  typically  in  the   first   stage   of 
lobar  pneumonia,  sometimes  in  incipient 
tuberculosis  at  the  apex  of  a  lung ;  rarely 
in   pulmonary  hemorrhage   and   oedema. 
They  may  frequently  be   found   at   the 
lower  part  of  the  posterior  aspect  of  the 
chest  for  a  few  deep  inspirations  in  feeble 
persons  who  have  been  in  the  recumbent 
posture  for  some  time. 
Indeterminate  Rales. 
Crumpling  sounds. 
Locality. 

Normal,  sometimes  heard  at  the  end  of 
a  forced  inspiration,  usually  bilateral. 
Abnormal,  they  are  sometimes  heard  in 
emphysema. 


88  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Cause,  none  known  definitely. 
Character,  something  like  the  sound  of 
parchment  when  wrinkled,  and  occur- 
ring at  the  end  of  forced  inspiration. 
Condition,  emphysema. 
Friction  Sounds, 

Locality,  over  inflamed  pleura  or  pericardium, 

rarely  over  the  peritoneum. 
Cause,  rubbing  together  of  two  serous  surfaces, 
roughened  by  exudate,  or  dry  from  diminished 
secretion. 
Character. 

Quality,  rasping,  grating,  grazing,  creaking, 
simulated  by  rubbing  the  hand  upon  the 
chest  during  auscultation.  They  are  few  in 
number  compared  with  rales,  and  are  irreg- 
ular in  occurrence. 
Duration,  they  are  not  removable  by  cough 

or  deep  inspiration. 
Rhythm,  usually  they  are  most  prominent  at 
the  end  of  inspiration  or  beginning  of  ex- 
piration. 
Condition,  pleurisy  and  pericarditis  in  the  first 
stage ;  rarely  in  peritonitis  over  the  spleen  or 
liver. 
Unclassified  Adventitious  Sounds. 
Metallic  Tinkling. 
Locality. 

Normally,  it  may  be  heard  at  times  over  the 

stomach. 
Abnormally,  over  the  pleural  cavity  contain- 
ing air  and  fluid,  especially  w^hen  com- 
municating with  a  bronchus  above  the 
level  of  the  fluid. 
Cause  :  the  dropping  of  fluid  in  a  cavity  con- 
taining fluid  and  air. 


METHODS  OF  PHYSICAL  DIAGNOSIS.  89 

Character. 

Qualify,  sihx'ry,  tinkling,  or  splashing. 
Fitch  J  high. 

Intensity,  slight,  but  variable. 
Rhythm,  either  in  inspiration  or  expiration, 
or   during   cough,  or  occasionally   inde- 
pendent of  them. 
Condition,  pneumo-hydrothorax,  pulmonary 
abscess,  et€. 
Splashing-  or  Succussion  Sound. 

Locality,  same  as  that  of  metallic  tinkling. 
Cause,  splashing  of  fluid  within  an  air-con- 
taining  cavity,    heard    when    the    body    is 
shaken,  with  the  ear  of  the  examiner  against 
the  surface,  over  the  part. 
Chaeacter,  splashing. 

Condition,  pneumo-hydrothorax  or  pneumo- 
pyothorax. 
Bell  Sound. 

Locality,  it  is  heard  over  a  large  air-contain- 
ing cavity. 
Cause  :  with  the  ear  against  the  cavity,  per- 
cussion is  made  upon  the  chest  at  the  oppo- 
site side  of  the  cavity,  two  coins  being  used 
as  plexor  and  pleximeter ;  the  sound  heard 
is  due  to  the  vibration  of  the  air  within  the 
cavity. 
Character,  ringing,  hollow,  metallic. 
Condition,  pneumothorax. 
SOUNDS  PRODUCED  BY  THE  CIRCULATORY 
MECHANISM. 
CARDIAC  SOUNDS. 

Normal  Cardiac  Sounds. 
First  Sound  of  the  Heart. 

Cause  of  the  first  sound  :  it  is  chiefly  due  to 
the  closure  of  the  auriculo-ventricular  valves 


90  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

(mitral  and  tricuspid).  To  a  slight  extent 
this  sound  may  also  be  due  to  contraction 
of  the  walls  of  the  ventricle  in  systole^  the 
impulse  of  the  apex  against  the  chest-wall, 
and  the  rush  of  blood  through  the  ven- 
tricles. 
Elements  of  the  first  sound. 

Mitral  element,  heard  best  at  the  apex,  and 
behind  at  the  angle  of  the  scapula.     It  is 
slightly  louder  than  the  tricuspid. 
Tricuspid  element,  heard  best  at  the  lower 
end,  a  little  to  the  left,  of  the  sternum. 
Character  of  the  first  sound. 

Quality,  "  lubb,^^  dull,  soft,  booming. 
Pitchy  lower  than  that  of  the  second  sound. 
Intensity,  greatest  at  the  apex  beat,  varying 
with  the  strength  of  the  heart,  the  condi- 
tion of  the  valves  and  cavities,  and  the 
amount  of  tissue  interposed  between  the 
heart  and  the  listening  ear. 
Duration,  long  as  compared  with  the  second 

sound. 
Rhythm,  systolic,  synchronous  with  the  sys- 
tole of  the  ventricles,  the  apex  beat,  and 
carotid  pulse ;  preceded  immediately  by 
the  long  pause,  succeeded  immediately  by 
the  short  pause. 
Second  Sound  of  the  Heart. 

Cause  of  the  second  sound :  it  is  chiefly  due 
to  the  closure  of  the  semilunar  valves,  aug- 
mented by  the  vibration  of  the  neighboring 
parts. 
Elements  of  the  second  sound. 

Aortic  element,  heard  best  in  the  second 
intercostal  space,  close  to  the  right  of  the 
sternum. 


METHODS  OF  PHYSICAL  UIAOyOSIS.  IJl 

Puhnonic  element,  heard  l)e.st  in  the  second 
intercostal  space  to  the  left  of  the  ster- 
num ;  not  so  loud  as  the  aortic. 
Character  of  the  second  sound. 

Quality,  "dupp,"  sharp. 

Fitch,  higher  than  that  of  the  first  sound. 

InteiiHity,  greatest  at  the  base  of  the  heart ; 
variable  like  the  first  sound. 

Duration,  shorter  than  the  first  sound. 

RJn/tJim,  it  is  preceded  immediately  by  the 
short  pause,  and  succeeded  immediately 
by  the  long  pause.  The  relation  of  the 
first  and  second  sounds  with  the  inter- 
vening pauses  may  be  represented  thus  : 

"lubb,"  — "dubb," . 

Modifications  of  the  Xonnal  Heart  Sounds, 
Modification  of  the  First  Sound,  in 
Intensity  and  duration. 

Diminished  intensity  of  the  first  sound,  from 
Weakness  of  the  heart  as  a  result  of — 

1.  General  diseases,  fevers,  chronic 
wasting  disorders,  aneurysm,  etc. 

2.  Local  diseases  of  the  heart :  fatty 
degeneration  or  infiltration  ;  atrophy, 
amyloid,  or  fibroid  degeneration ; 
valvular  disease ;  pericardiac  effu- 
sion, etc. 

Interposition  of  tissues,  as  in  emphysema, 
pleuritic  effusion,  thick  chest- walls  from 
fat  or  muscle. 
Increased  intensity  and  duration  of  the  first 
sound  ;  it  may  be 
Longer  in  duration,  loud  and  booming, 
as  in  hypertrophy  of  the  left  ventricle 
from  cirrhotic  kidney  ;  aortic  stenosis 
and  sometimes  in  aortic  aneurysm,  or 


92  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Shorter  in  duration    and  sharper,  as   in 
case  of  thin  chest-walls,  emotional  ex- 
citement,  physical   exertion,   onset  of 
febrile  disease. 
Quality  :  the  first  sound  may  be  impure  ;  it 
may  be  sharper  or  duller  than  usual,  more 
flapping  or  clacking. 
Khythm.  ^ 

Reduplication. 

Cause :    non-synchronous   action   of  the 
mitral  and  tricuspid  valves,  or  possibly 
non-synchronous  action  of  the  cusps  of 
either  valve. 
Character,  as  related  to  the  second  sound  ; 
it  may  be  represented  thus :  "  lubb,'^ 
"lubbV'  —  ^^dupp,"  — — . 
Frequency  :  it  is  not  uncommon,  but  the 
second  or  diastolic  sound  is  more  fre- 
quently reduplicated  than  the  first  or 
systolic  sound  of  the  heart. 
Significance  :  it  is  usually  temporary,  but 
may  be  permanent ;  it  is  either  physio- 
logical or  pathological,  and  it  is  not 
peculiar  to  any  particular  lesion  or  con- 
dition. 
Irregularity  may  involve  time  or  intensity, 

or  both. 
Intermittency  or  dropping  of  the  first  sound. 
Modification  of  the  Second  Sound. 
Intensity. 

Diminished  intensity  of  the  second  sound 

from 

Diminished  power  of   the  right  or  left 

ventricle,  by  which  less  blood  is  thrown 

into  the  aorta  and   pulmonary  artery, 

producing   less   tension  in  them,  and 


METHODS  OF  PHYSICAL  DIAGNOSIS  93 

hence,  less  forcible  recoil  of  their  elas- 
tic walls,  and  less  sudden  and  forcible 
closure  of  the  semilunar  valves. 

1.  General  debilitating  diseases,  or 

2.  Local  diseases  impairing  the 
strength  of  the  heart  or  elasticity 
of  the  main  arteries. 

Stenosis  of  the  mitral  or  tricuspid  orifices 
or  of  the  orifices  of  the  aortic  or  pul- 
monary artery,  reducing  the  tension  in 
those  vessels. 
Lesion  of  the  pulmonary  or  aortic  valves 
impairing  their  closure. 
Increased  intensity  or  accentuation  of  the 
second  sound. 
Pulmonic  second  sound  may  be  accen- 
tuated as  a  result  of  increased  tension 
in  the  pulmonary  artery  from  hyper- 
trophy  of    the    right    ventricle;    ob- 
structed pulmonary  circulation  depend- 
ent upon  pulmonary  disease  or  valvular 
disorder  of  the  left  heart. 
Aortic  second  sound  may  be  accentuated 
as  a  result  of  increased  tension  in  the 
aorta  from  hypertrophy  of  the  left  ven- 
tricle or  obstruction   in  the  aortic  or 
general  circulation :  chronic  renal  dis- 
ease  and    some    cases    of    aortic    an- 
eurysm. 
Quality  :  the  second  sound  of  the  heart  may 
be  sharper  or  duller,  or  flopping  or  more 
booming  in  character. 
Rhythm. 

Reduplication  of  the  second  sound. 

Cause  :    non -synchronous   action   of   the 
aortic  and  pulmonic  valves,  or  possibly 


94  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

non-synchronous  action  of  the  cusps  of 
either  of  these  valves. 
Character,  as  related  to  the  first  sound  it 
may   be     represented    thus:    "lubb," 
—  "  dupp/^  "  dupp/^  — . 
Frequency  and  significance  (vide  redupli- 
cation of  the  first  sound). 
Irregularity  and        ^ 

Intermittency  of  the  second  sound  (vide  first 
sound  of  the  heart). 
Abnormal  Cardiac  Sounds  or  3Iiir7nwrs, 
Exocardial  Murmurs. 

Pericaediac  friction  sounds. 

Locality,  over  the  prsecordia,  usually  best 
heard  over  the  base  of  the  heart,  or  over 
the  junction  of  the  left  fourth  costal  car- 
tilage with  the  sternum. 
Cause,  inflammation  of  the  pericardium 
causing  roughness  and  dryness  of  the 
membrane  in  the  first  and  at  the  end 
of  the  third  stage. 
Character. 

Quality,  rubbing,  grating,  rasping,  creak- 
ing- 
Intensity,  variable,   increased  by  forced 
expiration,  by  pressure  of  the  steth- 
oscope, and  by  forward  inclination  of 
the  patient.     They   seem  to  be   more 
superficial  than  endocardial  murmurs. 
Rhythm,  independent  of  respiration  and 
synchronous  with   systole   or  diastole, 
or  both. 
Pericardiac    splashing    and    churning 
sounds   have    been   heard    occasionally   in 
cases  of  sero-  or  pyo-pneumo-pericardium. 
Pleuro-pericardiac  friction  sounds  similar 


METHODS  OF  PHYSICAL  DIAGNOSIS. 


95 


in  character  to  pleuritic  friction  sounds,  but 
produced  by  the  motion  (jf  the  heart  in  sys- 
tole, causing  to-and-f'ro  rubbing  of  the  in- 
flamed pleura.  The  pleura  alone,  or  both 
the  pleura  and  pericardium,  may  be  in- 
volved in  the  inflammation. 


SVC 


Fig.  8.— Normal  blood-currents  in  the  heart  and  relative  position  of  the  ventri- 
cles, auricles,  and  great  vessels.  IVC,  inferior  vena  cava;  SVC,  superior  vena 
cava  ;  RA,  right  auricle :  TV,  tricuspid  valves ;  R  V,  right  ventricle :  P,  pulmonary 
valves  ;  PA,  pulmonary  artery  ;  Pv,  pulmonary  veins  ;  LA,  left  auricle ;  MV,  mitral 
valves ;  LV,  left  ventricle ;  A,  aortic  valves ;  Aa,  arch  of  aorta.   j;From  Page.) 

Pneumo-pericardiac  or  cardio-pulmonary 
sounds  are  soft  blowing  murmurs  of  rare 
occurrence,  produced  by  the  motion  of  the 
heart  in  forcing  air  from  an  adjacent  pul- 
monary cavity,  the  air  supposedly  being  ex- 
pelled from  the  cavity  in  systole  and  return- 
ing during  diastole. 
Endocardial  Murmurs  include  organic  and  in- 
organic, 


96  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Organic  endocardial  murmurs  include  val- 
vular and  non-valvular. 
Valvular,  organic,  endocardial  murmurs  in- 
clude systolic  and  diastolic. 
Systolic,  organic,  valvular  murmurs  in- 
clude those  of  the  right  and  those 
of  the  left  heart. 


Time     ( Direct  f  Aortic, 

of       <     (Obstructive).  1  Pulmonic 
■ t  Indirect  JK;iH 


;tive).  1 
iitant).  ' 

^^^m^^^^^^M  Short  tei^pi 

p^jgi|i^l|j^Mg^]^j^^j^l|^i^^  interval,  p^eg^^g^ 


Systole.  Time 

of 
murmurs. 


Systole  of  auricles. 


Y-i  t:/^     r  Aortic.  Time  f  Mitral. 

'~~  Direct 

(Obstructive). 


../  r  Aortic.  Time  fl 

™*  I      Indirect     ,  of  I 

,  I           (Regurgitant).  murmurs.  | 

™""-  [Pulmonic.  (Presystolic.)  [' 


Tricuspid. 
Indirect  '      Direct 

(Regurgitant).  (Obstructive), 

Fig.  9.— Diagram  showing  the  time  of  valvular  murmurs  in  the  cardiac  cycle. 
The  cardiac  cycle  is  divided  into  tenths.  The  first  sound  occupies  four-tenths ;  the 
short  interval,  or  silence  between  first  and  second  sounds,  occupies  one-tenth ;  the 
second  sound  occupies  two-tenths ;  the  long  interval  following  second  sound  occu- 
pies three-tenths ;  the  systole  of  the  ventricles  occupies  the  time  of  the  first  sound 
and  the  short  interval. 

Relation  of  murmurs  to  the  heart-sound :  murmurs  may  precede,  occur  with,  or 
take  the  place  of  the  heart-sounds.  Their  time  is  indicated  in  the  diagram  by 
arrows. 

1.  Of  the  left  heart. 

(a)  Mitral  systolic,  indirect,  or  re- 
gurgitant murmurs. 
Cause  :  insufficiency  of  the  mitral 
valve  from 

Tearing  or  perforation  of  a  cusp. 

Inflammatory  retraction  of  the 
cusps. 

Rigidity  of  the  cusps. 

Vegetations,  preventing  closure. 

Rupture  or  shortening  of  the 
chordae  tendinese. 

Dilatation  of  the  left  ventricle 
without  compensatory  length- 
ening of  the  chordae. 


METHODS  OF  PHYSICAL  DIAGNOSIS  97 

Spasm  of  the  cokimnse  carnete. 
Usual    accompanying    symptoms 
and  signs  : 

Pulse,  compressible  and  m<n-e  or 
less  irregular. 

Indications  of  pulmonary,  he- 
patic, and  renal  congestion 
with  oedema  of  the  feet  and 
ankles  are  common  in  cases 
of  non-compensation. 

Enlargement  of  the  left  heart, 
with  especial  increase  in  trans- 
verse diameter. 

Pulmonic  second  sound  accen- 
tuated. 
Character  of  the  murmur  of  mitral 
regurgitation  : 

Quality,  apt  to  be  blowing  and 
soft. 

Rhythm,  systolic,  accompany- 
ing, or  replacing,  the  first 
sound  of  the  heart  at  the 
apex. 

Intensity,  varies  in  different 
cases,  but  the  loudness  of  a 
murmur  is  not  proportionate 
to,  and  does  not  indicate  the 
severity  of  the  lesions  causing 
it.  This  is  equally  true  of 
all  organic  murmurs. 
Area  of  maximum  intensity  is  at 

the  apex. 
Propagation  of  the  murmur  is  fre- 
quently to  the  left  of  the  apex  ; 

it  is  often  heard  at  the  lower 

angle  of  the  scapula,  but  is  not 


98  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

usually  heard  at  the  base  of  the 
heart,  and  is  never  transmitted 
into   the  carotids.     The   trans- 
mission of  murmurs  to  the  left 
of  the  apex  depends  upon  the 
following  factors  : 
Time  :  whether  or  not  it  occurs 
when  the  apex  of  the  heart 
strikes  the  chest- wall  (systole). 
Enlargement  of  the  heart. 
Position  of  the  heart  relative  to 
the  transverse  diameter  of  the 
chest-cavity. 
Condition  of  the  left  lung. 
Thickness  of  the  chest-wall. 
Intensity  of  the  murmur. 
Frequency  of  the  murmur  of  mitral 
regurgitation,  it  is  the  most  fre- 
quent of  all  valvular  murmurs. 
(6)  Aortic  systolic,  direct  murmur. 
Cause : 

Obstruction  at  the  orifice, 
guarded  by  the  aortic  semi- 
lunar valve  due  to  thickening 
and  rigidity  of  the  cusps  from 
fibroid,  calcareous,  or  athero- 
matous change ;  vegetations ; 
adhesion  of  the  cusps ;  indu- 
ration and  contraction  of  the 
fibrous  ring  or  margin  of  the 
aortic  opening ;  congenital 
malformation  (rare). 
Simple  roughening  of  the  cusps. 
Marked  dilatation  of  the  aorta 
immediately  beyond  the  val- 
vular opening,  the  latter  re- 


METHODS  OF  PHYSICAL  DIAGNOSIS.  99 

maining  relatively  normal  in 
size. 
Usual    accompanying     symptoms 
and  signs  in  cases  of  marked 
obstruction  : 

Pulse  :  hard,  wiry,  small,  but 
regular  unless  the  heart  be 
greatly  embarrassed. 

Thrill  or  fremitus  often  felt  over 
the  base  of  the  heart,  espe- 
cially over  the  aortic  area. 

Evidence  of  cerebral  anaemia 
not  uncommon  ; 

Enlargement  of  the  left  heart ; 

Pulmonic  second  sound,  feeble  ; 
and 

Aortic  second  sound,  feeble  or 
inaudible. 
Character  of  the  aortic  direct  mur- 
mur : 

Quality,  usually  harsh  when  due 
to  stenosis  or  marked  obstruc- 
tion, otherwise  it  is  apt  to  be 
soft. 

Rhythm,  systolic,  with  the  first 
sound. 
Area  of  maximum  intensity  :  the 

right,  second  intercostal    space 

close  to  the  sternum,  sometimes 

over  the  left  interspace  or  over 

the  upper  part  of  the  sternum 

at  the  same  level. 
Propagation,  into  the  arteries  of 

the  neck  and  down  the  sternum, 

and  toward  the  apex,  but  with 

diminished  intensity.    It  is  also 


100  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

frequently  heard  when  loud,  be- 
hind to  the  left  of  the  fourth 
dorsal  vertebra,  but  is  not  usually 
transmitted  to  the  left  of  the 
apex. 
2.  Of  the  right  heart  (systolic,  organic, 
valvular  murmurs). 
(a)  Tricuspid  systolic,  indirect  or  re- 
gurgitant murmur. 
Causes  may  be  similar  to  those  of 
mitral  regurgitant  murmur,  but 
usually  it  results  from  relative 
incompetency  of  the  valve   in 
dilatation  of  the  right  ventricle, 
secondary   to    diseases    of    the 
lungs  or  serious  lesions  of  the 
left  heart. 
Usual     accompanying    symptoms 
and  signs  :  Commonly  pulmon- 
ary diseases  or  lesions  of  the  left 
precede  those  of  the  right  heart ; 
the  associated  manifestations  are 
often  those  of 

Congestion  of  the  brain  and 
abdominal  organs;    pulsa- 
tion of  the 
Jugular  and  sometimes  of  the 
Hepatic  veins. 

Enlargement    of    the    right 
heart  and  usually   of  the 
left. 
Pulmonic  second  sound,feeble. 
Character  of  the  murmur  of  tri- 
cuspid regurgitation  : 
Quality,  blowing. 
Rhythm,  systolic,  with  or  re- 


METHODS  OF  PHYSICAL  DIAGNOSIS.  101 

placing  the  first  .sound  of 
t!ie  heart. 
Area  of  niaximura  intensity,  the 
tricuspid  area  at  the  end  of  and 
along  the  left  side  of  the  sternum: 
Propagation  very  limited  ;  if  any- 
where, it  is  transmitted  to  the 
right,    sometimes    even   to   the 
axilla.     It  is  not  heard  at  the 
apex  or  behind  or  over  the  ca- 
rotids,  and   is   seldom  audible 
above  the  third  rib. 
Frequency :    it    is  com])aratively 
rare,  and  very  uncommon,  from 
primary  lesion  of  the  tricuspid 
valve. 
(6)  Pulmonic,  systolic,   direct  mur- 
mur. 
Cause :   usually  obstruction   from 
conditions  somewhat  similar  to 
those  affecting  the  aortic  orifice ; 
rarely  are  lesions  of  this  valve 
the  result  of  rheumatism.   They 
are  generally  congenital. 
Usual    accompanying     symptoms 
and  signs  : 
Enlargement  of  the  right  heart ; 
Evidence   of    venous   engorge- 
ment; 
Bruit    de    diahle     occasionally 

heard  over  the  jugulars. 
Pulmonic  second  sound  weak. 
Character  of  the  murmur  of  pul- 
monic obstruction  : 
Quality,    variable,    apt    to    be 
harsh. 


102  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Rhythm,  systolic,  accompanying 
the  first  sound. 
Area  of  maximum  intensity :   in 
the  left  second  intercostal  space 
close  to  the  sternum. 
Propagation    occasionally    toward 
the  left  shoulder,  never  toward 
the  apex  nor  along  the  aorta. 
It  is  not  heard  over  the  lower 
part  of  the   sternum,  nor   be- 
hind. 
Frequency  :  very  rare. 
Diastolic,  organic,  valvular  murmurs. 
1.  Of  the  left  heart. 

(a)  Mitral  diastolic  (presystolic),  di- 
rect murmur. 
Cause :   obstruction  of  the  mitral 
opening.       This   murmur   may 
possibly    occur,    according     to 
Flint,    without    mitral    lesion, 
where  there  is  aortic  regurgita- 
tion with  marked, dilatation  of 
the  left  ventricle. 
Usual     accompanying    symptoms 
and  signs : 
Pulse,  in  marked  cases,  small. 
Purring  thrill  or  fremitus,  pre- 
systolic and  most  distinct  at 
the  apex,  not  uncommon. 
Evidence  of  pulmonary  engorge- 
ment. 
Enlargement  of  the  left  auricle. 
Pulmonic  second  sound  accen- 
tuated. 
Character  of  the  murmur  of  mitral 
stenosis : 


METHODS  OF  PHYSICAL  DIAGNOSIS.  103 

Quality,  har.sli,  churning,  grind- 
ing, blubbering. 
Duration,  it  is  apt  to  be  longer 

than  other  murmurs. 
Rhythm,  diastolic  (presystolic), 
probably  occurring  in  auricu- 
lar systole. 
Area  of  maximum  intensity  :  at 
the  apex  beat  or  half  an  inch 
above  it.  Usually  louder  when 
the  patient  is  erect. 
Propagation  limited  :  not  trans- 
mitted to  the  left  of  the  apex, 
nor   into  the  arteries  of  the 
neck,  nor  is  it  heard  behind. 
Frequency  :  common. 
{h)  Aortic,  diastolic,  indirect,  regurg- 
itant murmur. 
Cause  :  insufficiency  of  the  valve 
from  much  the  same  causes  as 
those  producing  mitral  insuffi- 
ciency, except  those  referring  to 
the  chordae  tendinese. 
Usual    accompanying     symptoms 
and  signs : 
Pulse  full,  strong,  and  collapsing 
in  diastole ;  forcible  beating 
of  the 
Carotids. 
Capillary  pulsation  in  marked 

cases. 
Enlargement  of  the  left  heart, 
with   perhaps   secondary   en- 
largement of  the  right. 
Character  of  the  murmur  of  aortic 
regurgitation  : 


104  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Quality,  s(^ft,  blowing,  rushing, 

and  occasionally  musical. 
Rhythm,  diastolic,  accompany- 
ing,  or  replacing,  or  imme- 
diately following  the  second 
sound  of  the  heart.. 

Area  of  maximum  intensity  :  in 
the  right  second  interspace,  or 
over  the  sternum  at  the  level  of 
the  second  costal  cartilage,  fre- 
quently in  the  left,  second  in- 
terspace, and  sometimes  at  the 
xiphoid  cartilage. 

Propagation :  down  the  sternum 
to  the  epigastrium  ;  to  the  apex, 
where  it  is  sometimes  very  loud 
and  conveyed  to  the  left ;  to  the 
arch  of  the  aorta  and  into  the 
carotids ;  and  behind,  along  the 
right  side  of  the  spinal  column. 
It  may  be  heard  occasionally 
even  in  the  radial  and  femoral 
arteries.  The  area  of  diffusion 
is  greater  than  that  of  any  other 
murmur. 

Frequency  :  it  stands  third  in  order 
of  frequency. 
2.  Of  the  right  heart. 

(a)  Tricuspid,  diastolic  (presystolic), 
direct  murmur. 

Cause  :  obstruction  at  the  tricuspid 
opening  (vide  aortic  and  mitral 
stenosis). 

Usual  accompanying  symptoms 
and  signs :  those  of  systemic 
venous    engorgement.       Some- 


METHODS  OF  PHYSICAL   DIAGNOSIS  105 

times  there  is  a  fremitus  to  \)e 
felt  over  the  right  heart. 

Character  of  the  murmur  of  tri- 
cuspid obstruction  : 
Quality,  harsh. 
Rhythm,  presystolic. 

Area  of  maximum  intensity  :  over 
the  lower  two-thirds  of  the 
sternum. 

Propagation  :  may  be  toward  the 
base  faintly,  but  never  toward 
the  apex  ;  it  is  not  heard  above 
the  base. 

Frequency  :  extremely  rare. 
(6)  Pulmonic,  diastolic,  indirect,  re- 
gurgitant murmur. 

Cause :  insufficiency  of  the  pul- 
monic valve,  usually  following 
pulmonary  diseases  or  serious 
lesions  of  the  left  heart. 

Usual  accompanying  symptoms 
and  signs  are  those  of  the  ante- 
cedent lesion ;  evidence  of  venous 
engorgement ;  enlargement  of 
the  right  heart. 

Character  of  the  murmur  of  pul- 
monic regurgitation  : 
Quality,  soft,  blowing. 
Rhythm,  diastolic,  accompany- 
ing or  replacing  the  second 
sound. 

Area  of  maximum  intensity  :  over 
the  left,  second  intercostal  space. 

Propagation  :  downward  toward 
the  xiphoid  cartilage. 

Frequency  :  rare. 


106  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Non-valvula7'y  organic  murmur. 

Intra-ventriciilar  or  iiitra-auricular  mur- 
murs. 
Cause  :  roughening  of  the  endocardial 
lining  in  acute  endocarditis ;  rarely 
it  may  be  due  to  a  tendinous  cord 
stretched  across  the  ventricle  (con- 
genital) ;  or  cardiac  aneurysm ;  or  an 
abnormal  congenital  opening  between 
the  two  cavities,  patulous  foramen 
ovale. 

Usual  accompanying  symptoms  and 
signs  :  none  constant,  though  they 
may  be  those  of  acute  endocai'ditis. 
Character  of  the  organic,  intra-ven- 
tricular  murmur : 
Quality,  variable,  usually  soft. 
Rhythm,  systolic. 
Area  of  maximum  intensity  at   or 

near  the  apex. 
Propagation  :  limited. 
Frequency  :  quite  common  in  acute 
endocarditis. 
Inorganic,  or  functional,  endocardial 

MURMURS. 

Inorganic  valvular  murmurs. 

Systolic,  inorganic,  valvular  murmurs. 
1.  Of  the  left  heart. 

{a)  Mitral,  systolic,  inorganic,  re- 
gurgitant murmur. 
May  occur  purely  from  functional 
incompetence  without  actual 
lesion  of  the  valve.  Its  charac- 
ter does  not  differ  from  the  or- 
ganic murmur.  Such  a  murmur 
may  appear  and  disappear  with- 


METHODS  OF  PHYSICAL  DIAGNOSIS.  107 

out  previous,  accompanying,  or 
subsequent   evidence   of   endo- 
carditis. 
Frequency :    it   is   comparatively 
rare. 
(b)  Aortic,  systolic,   inorganic  mur- 
murs. 
Cause  :  antemia. 

Accompanying      symptoms     and 
siffus,  those  of 
Ansemia  :  pallor,  lassitude,  weak 

pulse, 
Venous  hum  over  the  jugulars, 

and  frequently  an 
Arterial,  systolic  murmur,  pro- 
duced in   the  carotids  which 
is  usually  of  different  quality 
and    pitch   from  the    cardiac 
murmur. 
No  cardiac  enlargement  is  present 
or  other  sign  of  valvular  lesion. 
Character : 
Quality,  soft. 
Rhythm,  systolic. 
Area  of  maximum  intensity  :  over 
the  base  of  the  heart,  above  the 
third  rib,  frequently  in  the  aortic 
area. 
Propagation  occurs  into  the  arch 
of  the  aorta  and  the  carotids ; 
frequently  a  louder  murmur  pro- 
duced in,  and  heard  over  the 
carotids,  may  accompany  it. 
Frequency  :  the  inorganic,  aortic, 
systolic  murmur  is  more  com- 
mon than  the  organic. 


108  PHYSICAL  DIAGNOSIS  OF  THE  CHEST 

2.  Of  the  right  heart. 

(a)  Tricuspid,  inorganic,  regurgitant 
murmur. 
Cause :    functional    incompetence 
of  the  tricuspid  valve,  similar 
to  that  of  the  mitral  valve. 
(h)  Pulmonic,  systolic,  inorganic  mur- 
mur. 
Cause  :  anaemia. 

Character:  similar  to  that  of  the 
aortic,  systolic,  inorganic  mur- 
mur. 
Area  of  maximum  intensity  is  over 

the  pulmonary  area. 
Propagation  is  limited :   it  is  not. 
transmitted  above  the  base  of 
the  heart,  but  may  be  accom- 
panied by  an  anaemic  murmur 
produced  in  the  carotids,  which 
is  frequently  of  different  quality 
and  pitch. 
Diastolic,  inorganic  murmur  of  both  left 
and  right  heart  are  very  rare  and  prac- 
tically unimportant. 
Inorganic,   non-valvular   murmurs   are   in- 
definite and  unimportant. 
VASCULAR  SOUNDS,  sounds  heard  over  the  vessels. 
Arterial  Sounds. 

Normal  Arterial  Sounds. 

Diastolic  second  sound  of  the  heart 
may  be  transmitted  into  the  aorta  and 
carotids.  (It  may  be  impure  or  entirely 
wanting.) 
Over  the  aorta  and  commonly  over  the 
carotid  and  subclavian  arteries  is  to  be 
heard  a  systolic,  indistinct,  rushing  sound 


METHODS  OF  PHYSICAL  DIAGNOSIS  109 

produced   by   the  blood   pulsating  through 
the  arteries. 

Over  the  Subclavian  arteries  at  the  end 
of  inspiration  a  systolic,  blowing  murmur 
may  be  frequently  heard  in  health. 

Over  the  abdominal  aorta  and  crural 
arteries  is  sometimes  to  be  heard  a  pulsating 
sound,  corresponding  in  rhythm  to  the  pulse 
in  those  arteries. 

Over  the  small  vessels  nothing  is  to  be 
heard. 

Pressure  of  the  stethoscope  over  any  of 
the  large  arteries  may  produce  a  murmur 
occurring  with  the  local  pulsation. 

Over  the  anterior  fontanelle  and  some- 
times over  the  carotids  of  children,  between 
the  ages  of  three  months  and  six  years, 
a  blowing,  systolic  murmur,  of  variable 
intensity,  is  frequently  heard,  ^'cerebral 
blowing." 

Over  the  uterus  in  the  latter  months  of 
pregnancy,  uterine  souffle,  from  entrance  of 
blood  into  the  dilated  arteries  of  the  uterus. 
Abnormal  Arterial  Sounds. 

Over  the  aorta,  carotid,  and  subclavian 
ARTERIES  may  be  heard  systolic  and  diastolic 
murmurs  produced  at  the  aortic  orifice  of 
the  heart ;  in  aneurysm  of  these  vessels  a 
systolic  whizzing  or  blowing  murmur  may 
be  heard  over  them,  rarely  a  diastolic  mur- 
mur in  aortic  aneurysm. 

Over  the  crural,  brachial,  radial,  and 
ULNAR  ARTERIES,  and  cvcn  the  peroneal 
and  dorsalis  pedis,  a  murmur  may  be  heard 
with  the  pulse  in  the  respective  vessels  in 
some  cases  of  aortic  insufficiency. 


110  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Over  the  crural  arteries  a  systolic  mur- 
mur may  sometimes  be  heard  in  anaemia  and 
chlorosis  and  in  high  fever  (as  well  as  occa- 
sionally in  health). 

Over  the  crural  arteries  a  double  mur- 
mur, diastolic  and  systolic,  may  be  heard  in 
some  cases  of  aortic  insufficiency  (Traube) ; 
exceptionally  in  mitral  stenosis  (Weil) ;  in 
lead-poisoning  (Matterstock) ;  and  in  preg- 
nancy (Gerhardt). 

Over  the  crural  arteries,  also,  in  many 
cases  of  aortic  insufficiency,  a  double  mur- 
mur may  be  produced  by  the  pressure  of  the 
stethoscope  over  the  artery,  "Duroziez's 
double  murmur."  This  can  only  occur  with 
a  large,  quick  pulse. 

Over  the  subclavian  artery  a  systolic 
murmur  (sometimes  normal,  as  when  due  to 
pressure  of  the  stethoscope)  may  be  pro- 
duced by  pressure  of  tumors  on  the  vessel ; 
traction  by  lung  in  fibroid  disease  of  the 
apex. 
Venous  Sounds,  bruit  de  diable. 
Normal  Venous  Sounds. 

Over  the  jugular  vein,  most  frequently 
the  right,  a  venous  hum,  whistling,  or  rush- 
ing sound  is  exceptionally  heard  in  health, 
either  continuous  or  rhythmically  syn- 
chronous with  diastole  or  inspiration.  It 
may  be  produced  sometimes  by  pressure  of 
the  stethoscope,  or  by  turning  the  person's 
head  to  the  opposite  side. 

Over  the  crural  vein,  occasionally  in 
health,  especially  in  thin  persons,  a  sound 
may  be  heard,  produced  by  sudden  straining 
effi^rts  or  coughing  (Friedreich). 


METHODS  OF  PHYSICAL  DIAGNOSIS,  111 

Abnormal  Venous  Sounds. 
Over  the  jugular  vein. 

In  tricuspid  inmfficieiwy  a  systolic  murmur 

may  sometimes  be  heard. 
In  ancemia  and  chlorosis  a  venous  hum  more 
or  less  continuous  is  often  present  over 
this    vessel,    associated    with    a    systolic, 
blowing  murmur  in  the  carotids.  Venous 
murmurs  arising  in  the  cervical  veins  and 
in  the  intratlioracic   venous  trunks  may 
exceptionally  be  conducted  to  tlie  heart, 
simulating  valvular  murnuirs. 
Cause  uncertain. 
Character. 

Quality  :  whizzing,   rushing,   or  hum- 
ming (like  a  singing  top). 
Duration  :  intermittent  or  constant,  but 

disappearing  with  the  anaemia. 
Intensity  :  loudest  over  the  right  jug- 
ular, with  the  patient  erect  and  the 
head  turned  to   the   left.      The  in- 
tensity is  increased  during  ventricu- 
lar diastole,  during  inspiration,  by 
moderate  pressure  of  the  stethoscope, 
and  by  quickening  of  the  circulation. 
Over  the  crural  veins,  exceptionally,  in 
tricuspid  insufficiency  may  be  heard  a  double 
sound,  indicating  first  auricular  then  ven- 
tricular contraction  (Friedreich) ;  this  is  not 
easily  distinguished  from  like  murmurs  pro- 
duced in  the  crural  artery. 

SUCCUSSION. 
The  succussion  or  splashing  sound  is  produced  in  a  cavity 
which  contains  both  fluid  and  gas,  by  shaking  the  patient. 
Normally,  it  may  sometimes  be  heard  over  the  stomach; 


112  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

pathologically,  it  is  a  sign  of  pneumo-hydrothorax.  The 
character  of  the  sound  is  like  that  produced  when  a  small 
keg,  partly  filled  with  liquid,  is  shaken  {vide  p.  89). 


PHONOMETKY. 

The  tuning-fork  may  aid  in  the  detection  of  changes  which 
have  affected  intrathoracic  organs.  ^If  it  be  vibrated  and 
placed  over  normal  lung  its  sound  is  accentuated;  if  over 
airless  parts  its  sound  is  attenuated. 


PHYSICAL  SIGNS  IN  THE  DISEASES  OF  THE 

CHEST. 

Note. — A  clear  understanding  of  the  morbid  anatomy  of 
a  disease  is  essential  to  an  appreciation  of  its  physical  signs. 
In  the  following  synopsis,  therefore,  each  disease,  with  a  few 
exceptions,  is  introduced  by  a  definition  epitomizing  its  gross 
pathology.  In  the  enumeration  of  the  signs  discovered  by 
the  several  methods  of  objective  examination  the  order  will 
be  followed,  as  far  as  practicable,  as  indicated  in  the  preced- 
ing pages — viz.  under  inspection,  color,  nutrition,  size,  form, 
posture  and  movements,  etc. 

DISEASES  OF  THE  CHEST-WALL. 

PLEURODYNIA  AND  INTERCOSTAL  NEURALGIA. 
Definition. 

PLEURODYNIA  is  a  thoracic,  rheumatic  myalgia. 
IKTEJRCOSTAL  NJEUMALGIA   is  a  functional  or 
organic  affection'  of  the   intercostal   nerves,   chiefly 
manifested  by  pain  and  localized  points  of  tenderness, 
and  usually  affecting  women. 


SIGNS  IN  THE  DISEASES   OF  THE  CHEST.         113 

Signs. 

INSPECTION  shows 

ANiCMIA  commonly  present. 

RESPIRATION  in  severe  oases  shallow  and  more  or 

less  rapid  as  evidence  of  ])ain. 
MOVEMENTS    OF   THE    BODY   restricted  to  avoid 
pain,  especially  in  pleurodynia. 
PALPATION  may  reveal 
IN  PLEURODYNIA — 

Tenderness  on  pressure,  more  or  less  diffuse  when 
superficial  muscles  are  involved. 
IN  INTERCOSTAL  NEURALGIA— 

Tenderness  in  from  one  to  three  Isolated  points 
(Valleix's). 
Behind,  near  the  dorsal  vertebrae. 
Laterally,  in  one  or  more  intercostal  spaces  along 

the  axillary  line. 
Anteriorly,   in   one  or  more  intercostal   spaces 
near  the  sternum  or  over  the  epigastrium. 
PERCUSSION  shows— 

ABSENCE  OF  DULNESS.  unless  there  be   compli- 
cating or  causative  disease  of  the  lungs,  pleurae,  or 
circulatory  organs. 
AUSCULTATION  yields— 

NORMAL  VESICULAR  RESPIRATION,  except  slightly 
diminished  in  intensity  or  interrupted  owing  to  re- 
stricted movements. 
ABSENCE  OF  PLEURITIC  SOUNDS  and  of  crepitant 
rales. 

SWELLINGS  AND  TUMORS  OF  THE  CHEST-WALL. 

Definition  :  these  include  inflammatory  and  granuloma- 
tous affections  and  tumors. 

Signs  :  the  varying  color,  size,  sliape,  location,  tenderness, 
consistence,  and  movability  of  each  aflPection,  whether 
originating  from  or  involving  bone,  cartilage,  or  soft 


114  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

parts,  are  properly  considered  in  works  on  general  sur- 
gery. Suffice  it  to  say  here,  that  the  usual  respiratory 
and  vocal  sounds  are  to  a  degree  obscured  over  them 
and  vocal  fremitus  correspondingly  enfeebled.  The  ab- 
sence of  positive  signs  of  intrathoracic  disease  is  sug- 
gestive of  one  or  the  other  of  these  affections. 

EMPHYSEMA  OF  THE  CHEST-WALL. 

Definition  :  a  rare  affection  characterized  by  inflation  of 
the  subcutaneous  areolar  tissue  with  air  or  other  gas.  It 
is  usually  associated,  when  marked,  with  a  like  involve- 
ment of  the  cervical  and  abdominal  region,  and  it  may 
extend  over  the  entire  body. 
Signs. 

INSPECTION  may  reveal — 
PALENESS  of  the  surface. 

PUFFIN  ESS,  tending  to  obliterate  the  usual  depres- 
sions and  prominences. 
APEX  BEAT  absent. 
PALPATION  reveals — 

PECULIAR  SENSE   OF  YIELDING  or  softness,  with 
crepitation  fremitus  felt  by  the  finger  tips  pressed 
upon  the  surface. 
AUSCULTATION 

CREPITANT  SGUNDS.myriad,  fine,  and  somewhat 
similar  to  the  rales  in  pneumonia,  heard  when 
the  ear  or  stethoscope  is  pressed  upon  the  surface. 


DISEASES  OF  THE  BEONCHI,   PLEUE^,  LUNGS,   AND 
MEDIASTINUM. 

ACUTE  AND  SUBACUTE  BRONCHITIS. 

Definition  :  inflammation  of  the  mucous  membrane  lining 
the  larger  and  medium-sized  tubes  of  both  lungs.  The 
early  dryness  and  swelling  is  followed  by  more  or  less 
profuse  secretion. 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST         115 

Signs. 

INSPECTION  reveals  little  abnormal  except— 
RESPIRATORY  MOVEMENTS  slightly  accelerated. 
COUGH  at  first  dry,  harsh,  with  scanty  secretion,  later 

moist  (loose),  rattling. 
DYSPNCEA  rarely,  except  from  retained  secretion  in 
the  tubes,  as  in  infants,  the  aged,  or  tlie  enfeebled. 
rALPATION  reveals— 

SURFACE  TEMPERATURE  and  pulse  slightly  mod- 
ified. 
VOCAL  FREMITUS  normal. 

RHONCHAL  FREMITUS  in  case  of  considerable  secre- 
tion, especially  in  children,  or  in  adults  with  thin 
chest- Avails. 
PERCUSSION. 

RESONANCE  normal. 

SLIGHT   DULNESS  rarely,  over  lower  part  of  the 
chest,  due  to  accumulation  of  bronchial  secretion, 
though  this  may  be  removed  by  expectoration. 
A  USCULTATION, 

RESPIRATORY  SOUNDS  apt  to  be  somewhat  harsh 

over  the  larger  tubes. 
VESICULAR   MURMUR  may  be  more    or  less   sup- 
pressed over  parts  of  the  lungs  supplied  by  bronchi 
partially  or  wholly  occluded  by  mucus. 
VOCAL  RESONANCE  normal. 
ADVENTITIOUS  SOUNDS. 

Dry  Bales  common  in  the  first  stage,  slightly  ob- 
scuring the  vesicular  murmur. 
Moist  Males  (large  and  small)  may  be  heard  bilat- 
erally in  varying  numbers  after  the  first  day  or 
so,  with  the  occurrence  of  hypersecretion.  These 
are  variable  in  intensity,  location,  and  time,  and 
are  apt  to  disappear  upon  cough,  and  upon  deej) 
inspiration  or  forced  expiration.  A  few  dry  rales 
may  occur  with  them. 


116  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

CAPILLARY  BRONCHITIS. 

Definition:    inflammation  extending  from  the  larger  to 

the  smaller  tubes  (bronchiolitis). 
Signs. 

INSPECTION,  in  addition  to  the  usual  visible  signs 
of  acute  bronchitis^  reveals  the  age. 
AGE,  young  children  or  the  aged. 
EXPRESSION  of  anxiety  or  distress  common. 
CONGESTION  and  a  more  or  less  bloated  appearance 

of  the  face  sometimes  seen. 
LIVIDITY  of  the  face  becomes  more  or  less  evident, 
both  from  want  of  proper  oxygenation  of  the  blood 
and  its  undue  accumulation  in  the  right  heart,  lead- 
ing to  a  fatal  termination. 
AL/E  NASI  dilated  in  the  struggle  for  air. 
THE  CHEST  in  a  young  child  may  be  notably  dis- 
tended at  the  anterior  upper  and  middle  part  from 
acute  compensatory  emphysema,  which  disappears 
if  recovery  occurs. 
GENERAL  RESTLESSNESS. 

DYSPNCEA,  amounting  sometimes  to  orthopnoea,  and 
HYPERPNCEA,  amounting  to  60  or  70  respirations  per 
minute  in  children. 
PALPATION. 

THE  SURFACE  IS  HOT,  and  later  may  be  covered 

with  clammy  perspiration. 
THE  PULSE  rapid,  weak. 
PERCUSSION  may  obtain 
NORMAL  RESONANCE,  or 

EXAGGERATED  RESONANCE  over  the  upper  lobes 
owing  to  emphysema,  which  compensates  for  occlu- 
sion of  the  many  small  bronchi  with  collapse  of 
their  terminal  air-vesicles. 
AUSCULTATION,  usually  the  signs  of 

GENERAL  BRONCHITIS  of  the  larger  tubes,  and  in 
addition 


SIGNS  TN  THE  DISEASES  OF  THE  CHEST.        117 

SIBILANT  RALES,  very  a})iiii(laiit  early  in  the  disease, 

replaced  latei-  by 
SUBCREPITANT  RALES,  both  bilateral. 

CHRONIC   BRONCHITIS. 

Definition  :     prolonged    inflammation    of   the   bronchial 
mucous  membrane.     This  means  derangement  of  secre- 
tion, thickening  and  irregularity  of  the  surface,  hyper- 
trophy of  the   muscular  and   fibrous  coats,   with  final 
atrophy    and    fibrosis,    eventuating    in    bronchiectasis, 
asthma,  or  emphysema. 
Signs  :  largely  those  of  acute  and  subacute  bronchitis. 
THE  CHIEF  CONTRAST  is  in  the  greater  number 
of  moist  rales  and  the  relatively  few  dry  rides  in  the 
chronic  affection.     As  the  disease  may  tend  to 
EMPHYSEMA,  and  frequently  to  more  or  less 
ASTHMA,  the  signs  are  correspondingly  modified. 
THE  ABSENCE   of  emaciation,  pallor,  tachycardia, 
hyperpnoea,  and  other  evidences  of  phthisis  is  espe- 
cially important. 

PLASTIC  BRONCHITIS. 

Definition  :  an  acute  or  chronic  inflammation  of  the  bronchi, 
chiefly  characterized  by  the  exudation  of  fibrinous  mat- 
ter, with  the  formation  of  plastic  casts  in  the  smaller, 
sometimes  involving  the  larger  tubes. 

Signs :  those  of  ordinary  bronchitis,  with  the  evidence 
of  partial  or  complete  obstruction  of  some  of  the  bronchi, 
detected  by  the  absence  or  diminution  of  the  respiratory 
sounds  over  the  affected  parts  and  dulness  over  collapsed 
lung. 

BRONCHIECTASIS. 

Definition  :  dilatation  of  the  bronchial  tubes  with  more 
or  less  associated  bronchitis,  fibrosis,  and  emphysema. 


118  PHYSICAL  DIAG2^0SIS  OF  THE  CHEST. 

Signs. 

IWSrECTION, 

DEPRESSION  OF  INTERCOSTAL  SPACES  and 
RIGIDITY    OF    THE    CHEST- WALL,    more    or    less 

marked,  commonly  unilateral. 
RESPIRATORY  MOVEMENTS  somewhat  limited. 
COUGH  with 

EXPECTORATION,  usually  very  profuse,   purulent, 
and  offensive.     At  times  more  profuse  in  certain 
postures. 
PALPATION  gives 

SIGNS  VARYING  greatly  from  time  to  time  with  the 
amount  of  secretion  retained  in  the  bronchiectatic 
cavities. 
Phonchal  FreniiUis  may  be  present. 
Vocal  Fremitus  may  be  abnormally  increased  over 
a  cavity  if  large,  and  freely  communicating  with 
the  upper  air-passages ;  diminished  when  the  com- 
munication is  closed. 

pehcussiox. 

DULNESS  usual  over  the  affected  lung;  most  com- 
monly over  the  right,  middle  and  lower  lohes.  It 
is  sometimes  removed  or  diminished  by  free  ex- 
pectoration, or  replaced  by  vesiculo-tympanitic, 
cracked-pot,  or  amphoric  resonance. 
A  USCUL  TA  TIOJV. 

RESPIRATORY  MURMURS  sometimes 

Suppressed  over  Cavities,  w  hile  respiratory  sounds 

are  apt  to  be  harsh  and  exaggerated. 
Broncho-vesicular  or  JBroncho-cavernous  respira- 
tion may  be  obtained  over  a  part  after  free  ex- 
pectoration, where  before  no  sounds  were  present. 
VOCAL  AND  WHISPER    SOUNDS  may   suffer  like 

changes. 
ADVENTITIOUS  SOUNDS  are  usually  present  in  the 
form  of 


SIGNS  I^'  TlIK  LISEASES  OF   THE  CHEST.  110 

Hales,  moist  and  dry,  and 

Gtfi'f/les,  both  of  which  are  varial)h*  in  character 
and  time. 

ASTHMA. 

Definition  :  a  neurosis  of  tlie  respiratory  mechanism,  char- 
acterized cliiefly  by  paroxysms   of  dyspnoea  probably 
due  to  s])asm  of  the  annular  bronchial  muscles. 
Signs  during  a  paroxysm. 
INSPECTION, 

POSTURE,   standing  or  sitting  with  elbows  on  the 

knees  or  resting  upon  some  support. 
EXPRESSION  OF  ANXIETY  and  distress. 
NOSTRILS  dilated,  MOUTH  open. 
PERSPIRATION  profuse,  commonly. 
STERNO-CLEIDO-MASTOID    MUSCLES    rigid   and 

prominent. 
CYANOSIS  of  the  face  and  neck  may  become  very 

marked,  conjunctivae  congested. 
CHEST  approaches  the  barrel-shape  or  inflated  type 

in  cases  of  long  standing  or  great  frequency. 
CHANGES  OF  POSTURE  usually  very  deliberate. 
RESPIRATORY  MOVEMENTS  restricted. 

Dl/sjJiioefc  (orthopnoea)  chiefly  expiratory,  and  res- 
piration not  necessarily  increased  in   rate,  but 
may  be  decreased. 
lusxyiratory  3Ioieineiifs  short  and  quick. 
Exjnratory  Movements  prolonged. 
PALPATION,    MENSURATION,  and    PERCUS- 
SION signs  not  specially  significant  except  when 
emphysema  has  develope<.l. 
PULSE  small,  feeble,  and  rapid  in  proportion  to  the 
deficient  aeration  of  the  blood  and  overdistention 
of  the  right  heart. 
SURFACE  OF  THE  BODY  cold  and  moist  (clammy). 
A  use  UL  TA  TION  gives 


120  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

COG-WHEEL  RESPIRATION,  harsh. 
RALES. 

Dri/  (sonorous  and  sibilant). 
Chiefly  in  Expiration. 
Over  Whole  Chest. 
Obscuring"  Vesicular  Murmur. 
Loud  enough,  usually,  to  be  heard  at  a  distance 
from  the  patient  (wheezing). 
Moist  (large  and  small,  subcrepitant), 

In  the  Later  Stage  in  proportion  to  the  bron- 
chitis with  accompanying  secretion. 

EMPHYSEMA  OF  THE  LUNGS. 

Definition  :  an  abnormal  inflation  of  the  lung  from  loss 
of  elasticity,  overdistention  of  the  air-vesicles,  and  in 
pronounced  cases  more  or  less  destruction  of  the  alveolar 
walls  by  rupture,  with  accumulation  of  air  in  the  inter- 
lobular connective  tissue. 
Signs :  in  senile  emphysema,  where  atrophy  of  the  lungs 
is  the  chief  feature,  and  in  moderate  emphysema,  there 
is  little  change  in  the  shape  of  the  chest. 
INSPECTION  in  well-marked  cases. 

FACE  apt  to  be  dusky  and  frequently  more  or  less 
swollen. 
Eyes  prominent  and  watery,  conjunctivae  injected. 
LipSf  end  of  Nose,  and  Tonifjiie  bluish. 
Nostrils  dilated. 
ALONG    ATTACHMENT   OF    DIAPHRAGM    there   is 
frequently  a   zone   of  dilated   venous   capillaries, 
though  this  is  not  peculiar  to  emphysema. 
POSTURE,  stooping. 

STERNO-CLEI DO- MASTOIDS  tense  and  prominent. 
NECK  apparently  shortened  and  thick,  owing  to  the 

elevation  of  the' sternum  and  shoulders. 
SHOULDERS  elevated  and  drawn  forward. 
FORM  of  the  chest  barrel-shaped. 


SIGNS  TN  THE  DISEASES  OF  THE  CHEST.        121 

General  Cmitour  rounding  out. 

Upper  Part  of  Htermitn, 

Infra-clavicular  and  Mammary  Re(/ions  prom- 
inent. 

Antero-posterior  Curvattire  of  the  spine  increased^ 
and  therefore 

Antero-posterior  Diatneter  of  the  eliest  increased. 
May  be  even  greater  than  the  transverse. 

Vertical  Diameter  apt  to  be  decreased. 

Loiver  Part  of  Chest  usually  contracted,  but  it 
may  be  dilated,  with  a  wide  obtuse  costal  angle. 

Intercostal  Spaces  wide,  especially  at  the  upper 
part  of  the  chest. 

Supra-clavicular  fossae  may  be  deepened  or  shal- 
low, or  bulging,  especially  during  cough. 

ScapuUe  separated  widely. 

Deep  Transverse  Depression  sometimes  present 
across  the  abdomen  at  the  level  of  the  twelfth 
rib,  especially  during  expiration. 

General  Emaciation, 
RESPIRATORY  EXPANSION  diminished. 

Breathing  Chiefly  Diaphragmatic. 

Ribs  and  Sternum  move  upward  and  forward  as 
if  made  of  one  piece. 

Intercostal  Spaces  and  supra-clavicular  fossse  fall 
in  markedly  during  forced  inspiration,  and  bulge 
out  during  expiration  and  cough. 

False  Ribs  and  neighboring  interspaces  retract 
during  inspiration. 

Dyspnoea  more  or  less  persistent  and  exaggerated 
by  attacks  of  bronchitis,  asthma,  and  on  ex- 
ertion. 

Inspiratory  Act  short  and  quick. 

Eix^piratory  Act  distinctly  prolonged. 
APEX   BEAT  of  heart  not  usually  visible,  except  in 

the  area  of  cardiac  flatness ;  the  pulsation  of  the 


122  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

enlarged  right  ventricle  is  connnnnicated  to  the  epi- 
gastrium through  the  left  lobe  of  the  liver. 
JUGULARS  prominent,  and  sometimes  pulsate. 
PALPATIOJV. 

SKIN  dry  and  harsh. 

VOCAL  FREMITUS  frequently  enfeebled,  but  it  may 

be  normal  or  exaggerated. 
APEX   BEAT  rarely  palpable ;  frequently  there  is  a 
systolic  impulse  in  the  lower  sternal  and  epigastric 
regions. 
MENSUHATION  shows  the  barrel 
SHAPE  of  the  chest  and 

DIMINISHED  RESPIRATORY  EXPANSION. 
rERCUSSION  yields 

HYPER- RESONANCE,  bilateral ;  in  exaggerated  cases 

the  note  is  high-pitched,  vesiculo-tympanitic. 
AREA  of  pulmonary  resonance  reaches  lower  than 
normal,  and  may  extend  to  the  costal  margin,  less- 
ening the  dulness  over  the  heart,  liver,  and  spleen, 
and  encroaching  upon  or  obliterating  the  areas  of 
flatness. 
AUSCULTATION, 

RESPIRATORY  SOUNDS. 
Length. 

Inspiratory  Sound  delayed  and  shortened. 
Expiratory  Sound  prolonged,  and  may  be  two 
or  three  times  as  long  as  the  inspiratory. 
Quality f  Pitch,  and  Intensity. 

In  typical  cases  both  sounds  are  low  in  pitch, 
soft,  breezy  in  quality,  and  diminished  in  in- 
tensity,  but   frequently   they   are   harsh   and 
blowing. 
ADVENTITIOUS  SOUNDS. 

Dry  Crackling  or  crumpling  at  the  end  of  inspira- 
tion and  beginning  of  expiration,  supposed  to  be 
produced  in  the  wall  of  the  vesicles. 


STONS  TN  THE  DISEASES  OF  THE  CHEST.         \2-\ 

VOCAL    RESONANCE    is    iiicroased,   <limiiiislic(l,   or 

iioi'iiial. 
HEART  SOUNDS  usually  feeble,  those  at  the  apex 
displaced  downward  and  to  the  right,  sometimes 
distinct  in  the  epigastrium. 
Pulmonary  (second)  sound   usually   distinct,  and 

may  be  accentuated. 
Mifrmui's  of  relative  tricuspid   insufficiency  may 

be  heard  when  there  is  great  dilatation  of  the 

right  ventricle. 

ATELECTASIS. 

Definition  :  congenital  (apneumatosis)   or  acquired  col- 
lapse of  the  lung. 
Signs. 

INSPECTION  usually  discovers  the  subject  a 
WEAK  SICKLY  INFANT. 
PALLOR  or  DUSKINESS  of  the  surface. 
EMACIATION  and  evident  great  prostration. 
RESPIRATORY  MOVEMENTS  feeble. 

Hijperpnoea,  in    children    60  to   80  per  minute, 

common. 
BJiythm  of  Mespiration  altered,  the  pause  follow- 
ing instead  of  preceding  inspiration. 
mjspnwa  marked  without  relatively  proportionate 

lividity. 
Petraction  of  the  Intercostal  Spaces  and  Loiver 

Pibs  marked  during  inspiration. 
Ifi  the  Newly-born  apneumatosis  is  denoted 
by  shallow,  rapid  respiration,  feebleness  of 
the  cry,  dyspnoea,  especially  evident  in  in- 
ability to  nurse  properly,  and  absence  of 
cough. 
PALPATION. 

EXTREMITIES  cold. 
PULSE  feeble  and  rapid. 


124  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

VOCAL   FREMITUS  normal  or  slightly  exaggerated 

over  the  base  of  both  lungs. 
PERCUSSION  is  less  satisfactory  in  children  than  in 

adults. 
NORMAL  RESONANCE,  if  the  collapsed  vesicles  are 

so  few  or  small  and  scattered  as  to  be  marked  by  the 

resonance  of  adjacent  over  distended  lung. 
DULNESS  more   or   less   marked   over  the  affected 

parts  where  of  considerable  area. 
A  USCULTA  TlOJSr, 

VESICULAR  MURMUR  frequently  normal  where  the 

percussion  note  remains  normal.     It  is  diminished^ 

and  the  breathing  harsh  and  broncho-vesicular  over 

large  patches  of  collapsed  lung. 
RALES  are  usually  numerous  except  in  apneumatosis. 

LOBAR  PNEUMONIA. 

Definition :    an   acute   infectious   disease,    characterized 
locally  by  inflammation  of  the  lung,  clinically  mani- 
fested in  three  stages. 
FIRST  STAGE,  EKGOBGEMEKT. 
SECOJSrn  stage,  consolidation  (red  and  gray 

hepatization). 
THIRD  ST  A  GE,  PBOGRESSIVE  BESOL  UTION 
Signs :  for  convenience  the  signs  of  the  three  stages  will 
be  considered  under  each  of  the  methods  of  physical 
examination.     The  signs  of  the  first  stage  are  usually 
present  within  the  first  twenty-four  hours  unless  the 
pneumonia  is  central. 
INSPECTION. 

POSTURE  is  often  on  the  affected  side. 
CIRCUMSCRIBED    FLUSH,  mahogany  colored,  over 

one  or  both  cheeks. 
GENERAL  PALLOR,  occasionally  at  the  onset  the  face 

has  a  dusky  hue  ;  later  sallow. 
LIPS,  deep  red  at  first,  they  become  cyanosed  with 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.         125 

greatly    disturbed    circulation    and    pale    at    the 
crisis. 
HERPES  labialis  very  frequent  (50  per  cent,  of  cases, 
Osier) ;  at  times  herpes  on  cheeks,  nose,  and  eyelids. 
SUDAMINA  accompany  profuse  sweating. 
JAUNDICE,  more  or  less  marked,  is  common  and  an 
early  sign,  not  apparently  related  to  hepatic  en- 
gorgement, but  probably  due  to  duodenitis. 
EXPRESSION  anxious,  eyes  bright  at  first,  later  dull 

or  expressionless. 
INTERCOSTAL  SPACES  not  filled  out  as  in  pneumo- 

or  hydrothorax. 
RAPID  LOSS  OF  FLESH  apparent  in  a  few  days. 
DELIRIUM  active,  violent,  or  low  and  muttering. 
SUBSULTUS  TENDINUM  attends  the  great  prostra- 
tion of  the  "  typhoid  state." 
CONVULSIONS  may  usher  in  the  attack  in  children. 
RESPIRATORY   MOVEMENTS  of  the  affected  side 
restricted,  markedly  so  in  extensive  consolidation 
of  the  lower  lobe ;  exaggerated  movements  of  the 
healthy   side.     In    double    pneumonia    respiratory 
movements    largely    diaphragmatic    and    inferior 
costal. 

Hyperpnoea  always  present^  30  to  80  per  minute. 
Ratio  between  respiration  and  pulse,  1  to  2  or 
even  1  to  1.5. 
Di/S2)ncea  frequent,  panting  in  character. 
Inspiratory  Act  short  and  superficial. 
Expiratory  Act  often  associated  with  a  grunt, 
especially  in  children.     Dyspnoea  depends 
upon  various  factors  : 
Amount  of  lung  involved. 
Rapidity  of  iNVOLVEiNrENT, 
Fever, 
Pain,  and 
Derangement  of  the  nervous  system. 


126  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Cough  frequent,   short,  hacking,  dry  in   the  first 
stage,  loose  during  resolution. 
MENSUMATION  may  show,  in  the  second  stage,  a 
very  slight  increase  in  the  volume  of  the  affected  side 
during  expiration. 
PALPATION  discovers  the 

SKIN  usually  hot  and  dry  till  the  crisis,  but  it  may 

be  moist  from  the  onset  (a  favorable  sign). 
PRESSURE  may  elicit  deep-seated  tenderness. 
VOCAL  FREMITUS  in  the 

First  Stage  is  not  affected  ;  in  the 
Second  Stage,  greatly  increased  over  the  consolida- 
tion, unless  this  be  central  or  pleuritic  effusion 
covers  it,  or  the  large  and  medium-sized  bronchi 
become    blocked    (massive    pneumonia),    or    if 
there  is  complicating  bronchitis  with  free  secre- 
tion. 
Third  Stage,  progressive   return    to   the   normal 
type. 
FRICTION  FREMITUS  maybe  obtained  in  some  cases 

owing  to  accompanying  pleuritis. 
LOCATION    OF   APEX    BEAT  may  show  the    heart 

slightly  displaced  away  from  the  affected  side. 
PULSE, 
Ma2)idity. 

In  Mild  Cases,  from  90  to  120. 
In  Severe  Cases,  from  120  to  160. 
In  Children,  100  to  200. 
Volume  and  Tension, 
At  Onset  it  is  full,  bounding. 
After  the  Third  or  fourth  day  it  becomes  com- 
pressible,  small,  weak,  and  may  be  dicrotic 
and  intermittent  in  unfavorable  cases. 
In  Old  Ag-e'the  radial  pulse  is  not  reliable,  and 
the  pulse  should  be  taken  at  the  apex  beat. 
PERCUSSION, 


SIGNS  IN  THE  DISEASES  OF   THE  CHEST.         127 

FIRST  STAGE. 

JJulness  increasing  at  the  end  of  the  first  stage  ex- 
cept in  central  pneumonia.    The  note  may  some- 
times be  vesiGulo-tyinpanitlc. 
SECOND  STAGE. 

Marked  Dulness  over    the   consolidation    witli  a 
sense  of  resistance  to  the  pleximeter  finger,  less 
than  in  pleurisy  with  effusion. 
Hjlper-resonance  over  the  healthy  parts. 
Tympmiitic  Note  occasionally, 

Over  Healthy  Lung-  adjacent  to  consolidation. 
Over  a  Consolidated  Upper  Lobe  due  to  con- 
duction of  resonance  from  the  trachea    and 
main  bronchi. 
Cracked-pot  Note  occasionally  over  relaxed  lung 
adjacent  to  the  consolidation. 
THIRD  STAGE. 

Dulness  slowly  diminishing  with  progressive  reso- 
lution ;  normal  resonance  established  only  after 
weeks. 
AUSCUL  TA  TION. 

RESPIRATORY  SOUNDS  are — 

Early  in  the  First  Stage  feeble,  and  apt  to  be  dry 

and  somewhat  harsh  over  the  affected  part. 
Later  it  becomes  broncho-vesicular.  In  the 
Second  Stage. 

Bronchial  Breathing",  provided  the  large  bronchi 

are  patulous. 
Exaggerated  Breathing  over  the  healthy  lung. 
Third  Stage. 
Breathing  becomes  broncho-vesicular,  approach- 
ing the  normal. 
VOCAL  SOUNDS. 
First  Stage  normal. 
Second  Stage. 

Bronchophony  and  frequently 


128  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Pectoriloquy  are  characteristic  of  complete  con- 
solidation, 
-^gophony  not  uncommon  about  the  upper  level 
of  the  fluid  if  little  pleuritic  effusion  accom- 
pany the  consolidation,  voice  sounds  being  ab- 
sent or  indistinct  below. 
Third  Stage. 
Bronchophony  and  Pectbriloquy  give  place  to 
exaggerated  vocal  resonance  approaching  the 
normal  sounds. 
ADVENTITIOUS  SOUNDS. 
First  Stage. 

Crepitant  Rales,  lasting  usually  from  12  to  24 
hours.     These  may  be 
Absent. 

(1)  If  stages  follow  each  other  rapidly. 

(2)  In  pneumonia  complicating  rheumatism. 

(3)  In  lobes  secondarily  attacked. 

(4)  They  are  absent  oftener  in  pneumonia 
of  children  than  in  adults. 

Second  Stage. 

Subcrepitant  Rales  may  or  may  not  be  present. 
Third  Stage. 

Crepitant  Rales  return,  ^'  crepitant  rale  redux/' 

but  are  largely  obscured  by  the  coarser 
Subcrepitant  Rales,  which  are  frequently  accom- 
panied by  a  few  dry  rales  and  more  or  less 
large  mucous  rales. 

LOBULAR  OR   BRONCHO-PNEUMONIA. 

Definition  :  this  is  essentially  an  inflammation  of  termi- 
nal bronchi,  with  their  branches  and  surrounding  air- 
vesicles,  which  make  up  the  pulmonary  lobules.  It 
occurs  in  the  course  of  bronchitis,  extending  to  tlie 
finer  tubes,  and  is  manifested  in  isolated  or  in  groups  of 
lobules.     These  show  interstitial  inflammation  of  both 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.         129 

tubes   and    air-cells,  both    being   filled   with    a    muco- 
purulent secretion. 
Signs  :  these  are  not  distinctive  unless  there  is  considera- 
ble consolidation,   and  even   then   rarely  sufficient  for 
diagnosis  without  the  aid  of  history  and  symptoms. 
INSJ^ECTIOK  shows  the  patient  usually 
AN  INFANT  or  in  ADVANCED  AGE. 
FACE  PALE  and  ANXIOUS,  becoming  CYANOTIC  in 

severe  cases. 
EMACIATION  very  rapid.     Chest  bilaterally  retracted 
at  the  lower  part,  where  there  is  extreme  pulmo- 
nary collapse  in  children. 
DYSPNCEA  marked. 

Inspiration  often  shortened  and 
Expiration  lengthened . 
HYPERPNCZA  constant. 

RESPIRATORY  MOVEMENTS  DEFICIENT. 
Slight  expansion  of  the  ribs. 

Elevation  of  the  chest-wall  at  the  upper  part,  and 
retraction  of  the  soft  parts  and  louver  ribs  on 
inspiration. 
COUGH  dry,  hacking,  non-paroxysmal,  painful. 
RESTLESSNESS  and  jactitation   in  children  gives 
place  to  lethargy  with  advancing  consolidation  and 
obstruction  of  the  bronchi. 
PALPATIONT  may  elicit 

VOCAL    FREMITUS,    slightly   increased   over   small 

areas,  where  neighboring  lobules  are  consolidated. 
PULSE  often  reaches  140  to  150  per  minute;  small, 
compressible,    feeble    after    the    first    twenty-four 
hours. 
PERCUSSION. 

DULNESS  more  or  less  marked,  but  in  patches  usually, 
bilateral  and   limited   to  the  posterior  and  lower 
regions  of  the  chest;  sometimes  unilateral. 
HYPER-RESONANCE  over  upper  and  anterior  part 

9 


130  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

of  chest  where  functional  emphysema  occurs  in  the 
corresponding  part  of  the  lungs. 
AUSCULTATION, 

VESICULAR  MURMUR  feeble. 

BRONCHO-VESICULAR  and  bronchial  respiration. 

VOCAL  FREMITUS  exaggerated. 

RALES,  moist  and  high-pitched  over  the  lower  part 
of  the  chest,  irregular  in  tiihe  and  place. 

UNDEFINED  MUCOUS  CLICKS,  on  forced  respira- 
tion. Signs  of  emphysema  are  frequently  found  over 
the  anterior  and  upper  part  of  the  chest. 

PULMONARY  TUBERCULOSIS. 

Definition  :  this  affection  is  extremely  varied  in  its  pri- 
mary location  and  manner  of  development,  and  there- 
fore needs  a  few  words  of  introduction. 

It  is  characterized  etiologically  by  the  entrance 
of  tubercle  bacilli  into  the  lungs  with  the  respired 
air  or  through  the  lymphatic  or  blood-vessels. 
Pathologically,  therefore,  the  initial  tubercle 
may  result  early  in  (1)  bronchial  ideeration,  or 
the  initial  lesion  may  be  in  the  small  tubes  of 
one  or  more  lobules,  giving  the  usual  early  catar- 
rhal signs  of  (2)  tubercular  bronchiolitis,  as  so 
often  manifested  at  one  or  the  other  apex,  and 
followed  pari  j^cissu  by  the  signs  of  consolida- 
tion as  the  neighboring  vesicles  become  involved. 
Again,  sudden  rupture  of  a  bronchial  lymphatic 
gland  or  other  tuberculous  focus,  with  aspiration 
of  its  infectious  contents  into  the  bronchi  of 
many  lobules,  may  result  in  rapidly  developing 
(3)  caseous  lyaeumoniay  involving  more  or  less 
of  one  lobe.  Finally,  the  entrance  of  a  large 
number  of  tubercle  bacilli  into  the  circulation, 
from  a  primary  systemic  focus,  and  their  wide 
dissemination  in  the  lung  (as  well  as  in  many 


S1G2^S  IN  THE  DISEASES  OF  THE  CHEST.         131 

other  organs),  results  in  (4)  acute  nilllarij  tuber- 
culosis, the  pulmonary  signs  of  which  are  insig- 
nificant. 

The  morbid  conditions  which  may  appear  in  the 
course  of  pulmonary  tuberculosis,  more  or  less 
slow  in  its  progress,  are  tubercular  bronchitis, 
lobular  and  lobar  consolidation,  the  formation 
of  cavities,    compensatory    emphysema,    fibrosis 
and  calcification,  bronchiectasis,  oedema,  collapse, 
and  pleiiritis,  with  or  without  effusion  or  pneumo- 
thorax. 
Signs  of  pulmonary  tuberculosis,  beginning  as  a  broncho- 
pneumonia. 
INITIAL    OR    CATARRHAL   STAGE  before  the 

advent  of  consolidation. 
INSPECTION. 

Color  and  Niitritiofi  may  not  be  much  affected. 

Flat  or  ^^  Alar  Cheaf  more  or  less  marked  in 
many  cases. 

JVo  Abnormal  Local  Retraction  of  the  chest  as  yet. 

Respiratory  Expansion  of  one  or  the  other  apex 
may  be  slightly  deficient  or  apparently  lagging 
as  compared  to  the  other. 

No  Hyperpnoea  as  yet. 
PALPATION  and  mensuration  negative,  or 

Pulse  rate  slightly  increased,  and 

Respiratory  Expansion  deficient  at  one  apex. 
PERCUSSION  negative. 
AUSCULTATION. 

Respiratory  Murmur  frequently  feeble,  having 
interrupted  or  cog-wheel  rhythm,  and  accom- 
panied by 

Subcrepitant  Rales,  which  may  be  feeble,  few, 
and  distant  at  an  early  stage,  but  become  more 
distinct.  Later  and  sometimes  early  the  respira- 
tory murmur  may  be  harsh,  occasionally  there  are 


132  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

A  Few  Sibilant  Rales. 

A  Mucous  Click  or  friction  or  indistinct  crumpling 
sound  may  be  heard. 
STAGE  OF  COJVSOLIlPATIOlsr  {tuberculosis). 

INSPECTION  yields,  in  addition  to  the  signs  of  the 
first  stage, 

Pallor  and  Emaciation, 

Hectic  Flush,  and  frequently  very  red  lips. 

Tenia  Versicolor,  common  on  the  surface  of  the 
thorax  and  other  parts. 

Betraction  of  the  supra-clavicular  and  infra- 
clavicular region  at  the  affected  apex. 

jUjperxrnoea,  superficial  breathing  and  a  tendency 
to  oough  on  deep  inspiration. 

Apeoc  Beat  enlarged  in  area  and  abnormally  rapid. 
PALPATION. 

Skin  hot  and  dry,  or  apt  to  be  bathed  in  perspira- 
tion. 

Bespiratory  Movements  diminished. 

Vocal  Fremitus  increased  over  consolidation.  It  is 
normally  greater  at  the  right  apex  than  the  left. 
Vocal  fremitus  may  be  diminished  if  the  pleura 
is  greatly  thickened  over  the  consolidated  lung. 

Pulse  rate  usually  above  a  hundred. 
PERCUSSION. 

Dtilness  above  and  over  the  clavicle,  or  in  the 
supra-scapular  region,  early ;  proportionately 
more  extensive  with  the  advance  of  consolida- 
tion. The  two  apices  should  be  percussed  while 
the  patient  holds  his  breath  after  full  inspira- 
tion, especially  to  elicit  the  presence  of  but  slight 
dulness. 
Dulness  corresponds  to  tlie  consolidation  in  any 

part  of  the  lung. 
Deep-seated  consolidation  with  overlying  normal 
lung  may  not  be  detected. 


SIGNS  IN  THE  DISEASES   OF  THE  CHEST.         133 

A  small  portion  of  superficial  ('oiisolidation,  with 
iindc'i'lying    and    surrounding    overdistended 
lung,  may  not  be  easily  detected. 
Dulness  in  any  case  may  be  in  part  due  to  the 
simple   acute   pneumonia   surrounding  tuber- 
cular consolidation,  which  may  clean  up,  leav- 
ing only  the  smaller  area  of  dulness  due  to 
the  tubercular  part. 
Tympanitic  liesonanre  at  times  may  be  obtained 
over  consolidation  adjacent  to  the  trachea. 
AUSCULTATION. 

Respiratory    Sounds    are    apt    to    be    harsh    and 
broncho-vesicular  or  purely  bronchial,  according 
to  the  amount  of  consolidation. 
Whisj)er  and  Vocal  Mesouance  are  apt  to  be  ex- 
aggerated and  bronchial.     The  latter  amounts  to 
pectoriloqny  when  the  consolidation  surrounds  a 
large  bronchus. 
Heart  Sounds  are  apt  to  be  exaggerated  over  neigh- 
boring consolidation,  and  the  second  pulmonic 
sound  is  frequently  accentuated. 
Adventitious  Souitds  are  more  or  less  numerous. 
Rales  large  and  small,  dry  and  moist,  often  pe- 
culiarly sticky  in  character. 
Friction  Sounds  are  often  present^  due  to  cir- 
cumscribed plenritis. 
STAGE  OF  THE  FOB3IATION  OF  CAVITIES, 
INSPECTION  show^s  usually — 

Pronounced  Ancemia   and   Emaciation,  and   in 
exaggerated  cases  signs  of  poor  circulation,  such 
as  local  cyanosis  of  lips,  nose,  and  extremities. 
Cluhhiny  of  the  Fingers. 

Face  is  apt  to  bear  the  impress  of  prolonged 
wasting  illness,  drawn  haggard  expression  (ex- 
ceptionally cavities  may  be  formed  in  cases 
apparently  healthy). 


134  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Marked  Depression  of  the  chest  from  retraction 
of  the  aflPected  lung. 

Hespiratorj/  Movements  limited,  on  the  affected 
side  and  abnormally  rapid. 

Apex  Beat  rapid,  weak,  and  frequently  displaced 
toward  the  affected  side. 
PALPATION. 

Vocal  Fremitus  increased  oVer  a  cavity  if  empty 
and  freely  communicating  with  a  bronchus. 

Mhonchal  and  Friction  Fremitus  commonly 
present. 

Fulse  small,  compressible,  feeble,  and  rapid. 
PERCUSSION  in  the  stage  of  cavities  (see  also  pages 
68  and  69). 

JDulness  of  consolidation  is  modified  by  the  res- 
onance of  a  cavity. 

Am2)horic  or  Cracked-2)ot  Resonance  when  a 
cavity  communicates  more  or  less  freely  wdth  a 
bronchus.  The  resonance  disappears  w^th  the 
filling  of  a  cavity  with  fluid.  Sometimes  even 
a  large  cavity  communicating  freely  with  a 
bronchus  gives  dulness  or  cracked-pot  resonance 
when  the  patient^s  mouth  is  closed,  but  marked 
amphoric  resonance  with  the  mouth  open  (see 
Wintrich's  change  of  sound,  p.  69). 

Small  cavities  deeply  located  are  not  easy  and  are 
often  impossible  to  locate  by  percussion. 

Numerous  Isolated  Cavities  at  the  apex  without 
much  fibrosis  or  pleuritic  thickening  may  give 
resonance  not  far  from  the  normal  vesicular  res- 
onance, in  contrast  to  the  auscultatory  signs. 
AUSCULTATION  in  the  stage  of  cavities  when  the 
cavity  is  empty  and  freely  communicates  with  a 
bronchus. 

jRespiratory  Sounds, 

Cavernous  Respiration,  soft  blowing  or  puffing 


SIGNS  IN  Tin:  DISEASES  OF  THE  CHEST.  135 

in  character,  the  expiratory  sound  pn)l(»ii<^e<l 
and  l()\v-j)itched. 
Broncho-cavernous  Respiration,  when  tlie  cav- 
ity is  not  large  and  is  snrroiinded  ])y  consoli- 
dation. 
Amphoric  Respiration,  wliich  is  more  metallic 
and    resonant    than    cavernous   respiration,  is 
heard  in  exceptional  cases. 
Vocal   and    WJiisperinf/    Sounds    correspond    in 
change  to  the  respiratory  somids.     Vocal   res- 
onance amounts  to  pectoriloquy.     If  the  cavity 
is  filled  with  fluid  or  its  opening  closed  none  of 
these  sounds  may  be  heard. 
Adventitious  Sounds. 

Rales,  dry  and  moist  and  gurgling. 
Metallic  Tinkling-,  occasionally. 
In  most  cases  of  advanced  phthisis  the  pulmonary 
signs  of  all  three  stages  may  be  present,  de- 
pending upon  the  pathological   condition  of 
the  part. 

FIBROID   PHTHISIS. 

Definition  :  a  chronic  inflammatory  affection  of  the  lung 
characterized  pathologically  by  more  or  less  hyperplasia  of 
the  peribronchial,  inter-alveolar,  and  inter-lobular  con- 
nective tissue  and  pleura,  which  in  contracting  encroaches 
upon  the  lumen  of  vessels  and  air-passages.  The  fibrosis 
is  accompanied  by  degenerative  processes  and  often  by 
tuberculosis.  The  signs  in  a  typical  case  are,  therefore, 
out  of  proportion  to  the  relatively  mild  symptoms,  which 
are  those  of  chronic  bronchitis. 
Signs. 

INSPECTION  may  reveal — 

NUTRITION  and  COLOR  but  little  changed. 
FLATTENING   OR    RETRACTION  of   the  chest-wall 
over  the  affected  side. 


136  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

DEPRESSION  OF  THE  CORRESPONDING  SHOUL- 
DER, influencing  posture. 

DYSPNOEA  may  or.  may  not  be  apparent. 

COUGH  frequent  and  variable. 

RESPIRATORY  MOVEMENTS  limited  on  the  affected 
side ;  increased  on  the  opposite  side  except  late  in 
the  case,  after  the  unaffected  lung  has  become  em- 
physematous. 

HEART   dislocated   toward  the  contracted   lung,  as 
evidenced  by  the  apex  beat. 
rALBATION  frequently  elicits — 

EXAGGERATED  VOCAL  FREMITUS  over  the  con- 
tracted lung,  though  the  greatly  thickened  pleura 
and  contracted  bronchi  may  diminish  vocal  fremitus 
in  some  cases. 

PULSE   more   or  less  rapid  according  to  the  inter- 
ference with  respiration  or  the  amount  of  infection 
or  fever  present. 
PERCUSSION  gives— 

DULNESS  over  the  affected  part. 

EXAGGERATED  RESONANCE  on  the  sound  side,  fre- 
quently extending  across  the  mid-sternal  line  and 
to  the  limits  of  the  pleural  cavity  (to  the  costal 
arch)  below. 
AUSCULTATION  gives— 

BRONCHIAL  BREATHING  and  BRONCHOPHONY, 
and  frequently  feeble  respiration  on  the  affected 
side.     Vesicular  murmur  absent. 

EXAGGERATED  OR  NORMAL  breathing  on  the 
sound  side. 

VOCAL  RESONANCE  more  or  less  bronchial  over 
the  affected  side. 

ADVENTITIOUS  SOUNDS  variable. 

RALES  dry  or  moist  are  common. 


SIGNS  IN  THE  DISEASES   OF  THE  CHEST.         \:U 

PULMONARY   HYPER/EMIA. 

Definition  :  excess  of   blood   in   tiie   puhiionary   vessels 

(active  or  passive). 
Signs  not  distinct,  apart  from  sudden  dyspnoea  and  otlier 

signs  of  pulmonary  oedema. 

PULMONARY   CEDEMA. 

Definition  :  a  serous  transudate  into  the  vesicular  and 
interstitial  tissues  of  the  lung.     It  usually  affects  the 
most  dependent  parts  of  the  lungs. 
Signs. 

INSPECTIOX  and  PALPATION, 
CYANOSIS. 
HYPERPNCEA. 

DYSPNCEA  (sudden  in  occurrence). 
COUGH  \yith  frothy  sputum. 

SIGNS   OF   GENERAL   DROPSY   and  its  causative 
disease,  such  as  ansemia,  cardiac  disease,  or  scor- 
butus, may  be  present. 
PERCUSSIOX. 

DULNESS  over  the  lower  portion  of  one   or  both 
lungs. 
A  USCULTATION, 

R ESP!  R ATO RY  MURMUR  vesicular  or  slightly  bron- 
cho-vesicular, but  feeble. 
RALES    abundant,   fine,   subcrepitant,   usually  heard 

both  in  expiration  and  inspiration. 
VOCAL  RESONANCE  normal,  or  it  may  be  slightly 

increased. 
PULMONIC  SECOND  SOUND  is  apt  to  be  accen- 
tuated. 

PULMONARY   HEMORRHAGE. 
Bronchial  Hemorrhage. 

DEFINITION:    hemorrhage    from    the   ^yall    of    a 
bronchial  tube  or  the  trachea. 


138  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

SIGNS:  often  none  at  all,  except  congh  and  Ii?emopty- 
sis.     During  hemorrhage  and  for  hours  following 
it,  may  be  found 
RALES  large  and  small,  moist  in  character,  over  the 

same  part  of  the  chest,  and 
FEEBLE  RESPIRATION  and  perhaps  slight  dulness. 
Pulmonary  Apoplexy. 

DEFIJS ITION :  extravasation  of  blood  from  a  rup- 
tured vessel  into  the  lung  tissue.     It  is  rare,  and 
usually  occurs  in  the  lower  lobes. 
SIGNS^ 

INSPECTION   usually  reveals  if  the  hemorrhage  is 
large. 
Di/spnwa  with  cough  and  hcemoptysis. 
PALPATION  practically  negative. 
PERCUSSION. 

Dulness  more  or  less  extensive  unless  the  patches 
of  hemorrhagic  infarcts  are  few  and  small  or 
deeply  seated. 
AUSCULTATION  reveals — 
JEarlpf 

Rales,  moist,  large  and  small,  and  possibly  crepi- 
tant in  the  region  of  the  hemorrhage,  previous 
to  coagulation. 
Later,  after  coagulation,  the 

Respiratory   Murmur   is   apt  to  be  feeble   or 
suppressed,  especially  with  the  blocking  of  a 
bronchus  of  large  size. 
Bronchial  Breathing*  and  Voice  may  be  more 
or  less  marked  in  some  cases. 

PULMONARY  THROMBOSIS  AND   EMBOLISM. 
Definition. 

PULMONAItY  THROMBOSIS  is  a  gradual  ob- 
struction of  a  pulmonary  artery  (venous  radical)  or 
one  of  its  branches  by  a  clot  formed  in  situ. 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.         139 

PULMONARY  EMBOLISM  is  a  siulden  bbjcking 
of  a  pulmonary  vein  or  bronchial  artery  by  a  foreign 
body,  usually  a  fragment  of  a  vegetation  from  a  car- 
diac valve  or  a  fragment  of  a  thrombus  from  some 
of  the  systemic  veins. 

Signs. 

INSPECTION  and  PALI* A  TION  may  reveal  dys- 
pnoea, cyanosis,  and  rapid  heart,  and  possibly  pulsa- 
tion of  the  jugulars. 

PERCUSSION  may  elicit  exaggerated  resonance  over 
the  depleted  area  resulting  from  increase  of  air  in  the 
cells  corresponding  to  the  decrease  of  the  blood  in 
their  walls. 

AUSCULTATION. 

RESPIRATORY    MURMUR   feeble  or  suppressed  in 
the  same  area. 

PULMONARY  ABSCESS. 

Definition :  a  circumscribed  collection  of  pus  within  the 

lung. 
Signs. 

INSPECTION  may  reveal — 

PALLOR,    EMACIATION,   and  evidences  of  pyrexia 

and  prostration. 
DEPRESSION     OF     THE     CHEST-WALL    may     be 
present,  with   atrophy  of  the   intercostal  muscles 
over   a   cavity   Avhere   this   is   large    and    super- 
ficial. 
DYSPNOEA,  COUGH,  and  sometimes  marked  bulging 
of  the  intercostal  spaces  over  the  cavity   during 
cough. 
PALPATION. 

VOCAL   FREMITUS. 
Decreased  at  first,  and 

Increased  over  the  cavity  when  large,  superficial, 
and  freely  communicating  with  a  bronchus. 


140  PHYSICAL  DIAGNOSIS  OF  THE  CHEST.  ■ 

PERCUSSION, 

DULNESS  circumscribed  or  general  in  case  of  pneu- 
monia, giving  place  to  tympany  over  the  cavity  if 
of  sufficient  size  (see  p.  68). 
AUSCULTATION 

RESPIRATORY  MURMUR  feeble  or  absent,  or  some- 
times bronchial  over  the  abscess.  . 

INDISTINCT  RALES,  and  after  escape  of  the  pus  the 

SIGNS  OF  A  CAVITY. 

PULMONARY  GANGRENE. 

Definition  :  necrosis  of  lung-tissue,  accompanied  by  de- 
composition. It  may  occur  in  one  or  more  sharply 
defined  foci,  varying  from  the  size  of  a  pea  to  that  of  a 
hen's  eggy  usually  in  the  periphery  of  the  lower  lobe. 
More  rarely  it  is  diffuse,  involving  more  or  less  of  one 
lobe  or  the  whole  of  one  lung. 
Signs  are  not  distinctive,  as  the  same  may  be  present  in 
other  forms  of  phthisis. 

The  odor  of  the  breath  is  well-nigh  pathognomonic. 
INSPECTION 
COUGH. 

Temporary  in  circumscribed  gangrene. 
Persistent  in  the  diffuse  form. 
HYPERPNCEA  largely  in  proportion  to  the  amount 

of  lung  involved. 
CIRCUMSCRIBED   DEPRESSION   of  the  chest-wall 
toward  recovery. 
PALPATION 

VOCAL  FREMITUS  normal,  absent,  or  increased. 
PERCUSSION. 

DULNESS  or  flatness  over  the  gangrenous  foci,  and 
surrounding  consolidation  if  sufficiently  extensive. 
AMPHORIC  OR  CRACKED -POT  resonance  with  the 
formation  of  cavities  in  case  the  patient  survive. 
A  USCUL  TA  TION 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.         141 

RESPIRATORY  MURMUR  absent,  or  feeble  bronchial 
breathing  over  the  foci,  largely  dei)en(lent  upon  the 
openness  of  the  corresponding  larger  tubes. 

AMPHORIC  or  CAVERNOUS  RESPIRATION,  with 
the  formation  of  cavities,  if  freely  communicating 
with  a  large  bronchus. 

ADVENTITIOUS  SOUNDS. 

Rales  moist  in  character  are  apt  to  be  present. 
Gurgling  Sounds  with  the  formation  of  cavities. 

PULMONARY   CANCER. 

Definition  :    sarcoma   or  carcinoma  of  the  lung  rarely 
primary,  and  when  secondary  either  involving  the  part 
by  contiguity   from    primary  affection    of   neighboring 
organs,  as  the  cesophagus  and  liver,  or  metastasis,  as 
emboli  from  a  distant  focus. 
Signs  :  these  vary  with  the  character,  extent,  and  location 
of  the  tumor.     The  signs  may  be  those  of  bronchitis, 
pneumonia,  or  tuberculosis  in  any  of  its  stages.    Nodular 
cancer  may  give  few  or  all  of  the  following : 
INSPECTION. 
CACHEXIA  evident. 

LOCAL  enlargement  of  superficial  veins. 
RETRACTION  of  the  chest-wall,  depending  upon  col- 
lapse of  the  lung. 
BULGING  or  fulness  when  the  tumor  is  large  or  ac- 
companied by  pleuritic  effusion. 
PALPATION. 

VOCAL  FREMITUS  feeble  or  absent. 
PERCUSSION. 

DULNESS  or  flatness  over  the  lung,  or  possibly  nor- 
mal resonance  surrounded  by  dulness. 
A  use  UL  TA  TION. 

RESPIRATORY  SOUNDS  feeble  or  possibly  bronchial. 
VOCAL  SOUNDS  feeble,  sometimes  bronchophony. 
ADVENTITIOUS  SOUNDS,  rales,  etc.,  variable. 


142  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

ENLARGED  BRONCHIAL  GLANDS. 

Definition  :  enlargement  of  the  lymphatic  glands  which 
lie  at  the  bifurcation  of  the  trachea  and  about  the  main 
bronchi  is  rare  as  an  independent  disorder,  and  is  chiefly 
of  interest  as  a  local  manifestation  of  tuberculosis  or 
malignant  growths  or  syphilis. 
Signs. 

INSPECTION,  \ 

EMACIATION  and  hectic  flush  and  other  visible  evi- 
dences of  tubereulosis  may  be  present. 
CERVICALVEINS  may  be  distended. 
CYANOSIS  present  when  there  is  marked  pressure 

upon  large  venous  radicles. 
RESPIRATORY  MOVEMENT  deficient  on  one  side  as 

a  result  of  pressure  upon  a  main  bronchus. 
COUGH  dry,  ringing,  paroxysmal,  a  common  sign. 
DYSPNCEA  common. 
rALPATION. 

TENDERNESS  in  the  inter-scapular  region  near  the 
fourth  or  fifth  rib  is  occasionally  present. 
PEBCUSSION. 

DULNESS  over  the  glands  when  they  are  greatly  en- 
larged.    Dulness  uniform  over  one  side  may  result 
from   pulmonary  collapse  from   occlusion   of  the 
main  bronchus. 
AUSCUL TA TION  usually  discovers — 

MURMURS,  arterial  and  venous,  from  pressure  upon 

corresponding  vessels. 
RESPIRATORY   SOUNDS  feeble   or  absent  on   one 
side,   owing  to   pressure   on   the   main  bronchus. 
Deep  respiration  may  develop  sounds  not  present 
in  ordinary  respiration. 
VOCAL  SOUNDS  also  diminished  for  the  same  reason. 
ADVENTITIOUS  SOUNDS,  rales  are  apt  to  be  present 
owing  to  the  secretion  within  the  tubes  as  a  result 
of  bronchitis. 


SIGNS  IN  THE  DISEASES   OF  TILE  CHEST.         ll.j 

HYDATID  CYSTS  OF  THE  LUNG. 

Rare,  usually  secondary  to  hydatids  of  the  liver.    Signs 
fairly  distinct  when  the  cysts  are  large. 
Signs. 

INSPECTION, 

DECUBITUS  upon  the  sound  side. 

SLIGHT  BULGING  of  the  intercostal  spaces  over  the 

cyst,  and  possibly  slight 
ENLARGEMENT  of  the  affected  side. 
RESPIRATORY  MOVEMENT  limited  on  the  affected 
side  and  increased  on  the  sound  side. 
PALPATION, 

VOCAL  FREMITUS  absent  over  the  cyst. 
FLUCTUATION  may  sometimes  be  detected  when  the 
cyst  is  large  and  superficial. 
PERCUSSION. 

DULNESS  or  flatness  circumscribed  over  the  cyst,  sur- 
rounded by  resonance.     Dulness  unchanging  with 
posture  of  patient. 
A  USCULTA  TION, 

RESPIRATORY  MURMUR  absent  over  areas  of  flat- 
ness, normal  or  slightly  broncho-vesicular  imme- 
diately around  it. 

PLEURISY,  acute,  subacute,  and  chronic. 

Definition  :  an  inflammation  of  the  pleura,  characterized 
locally  by  early  dryness  of  the  pleuritic  surfaces,  fol- 
lowed by  the  exudation  of  fibrinous  lymph  and  more  or 
less  fluid.  The  latter  is  attended  by  proportionate  com- 
pression of  the  lung,  displacement  of  the  organs,  and 
interference  with  normal  functions.  There  may  be  more 
or  less  complete  resolution  or  crippling  of  the  limg  by 
thickening  of  the  pleura  and  adhesions,  with  permanent 
disarrangement  of  normal  organic  relations. 

Signs. 

AT  THE  ONSET  of  an  attack. 


144  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

INSPECTION. 
Posture  usually  on  the  sound  side  to  relieve  pres- 
sure from  the  inflamed  pleura. 
Hyiferpnwa  due  to 
Fever,  or  in 

Compensation  for  shallow  respiration. 
Limited  3Iovement  (slight)  on  the  affected  side  to 

avoid  pain. 
Increased  Movement  on  the  sound  side. 
PALPATION  may  elicit — 

Friction  Fremitus  on  the  affected  side. 

Surface  Temperature  possibly  higher  on  affected 

side. 
Tenderness  or  pain  upon  deep  pressure  on  affected 
side.     In  diaphragmatic  pleurisy  pain  may  be 
elicited  at  the  tenth  rib  at  the  insertion  of  the 
diaphragm. 
PERCUSSION  negative  except  for  the  production  of 

pain. 
AUSCULTATION. 

Vesicular  Murmur  on  the  affected  side. 
Diminished  in  intensity  and  duration  owing  to 

the  restrained  respiratory  movements. 
Rhythm  Disturbed,  jerky,  cog-wheel. 
Friction  Sounds, 
Pleuritic. 

Area  circumscribed  or  diffused. 
Time,  Avith   inspiration   and   expiration,  but 
most  marked  in  the  former  and  broken  and 
jerky  in  rhythm. 
Chaeacter,  superficial  and  fine,  grazing  or 
coarse,    creaking ;    or   grating,    rasping,   or 
sawing  in  sound. 
Pleuro-pericardiac  Friction  Sounds. 

Area    usually    most    distinct    at    the    apex 
or   along  the  right  or  left  border  of  th^ 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST         145 

heart,  where  the  pleurisy  is  adjacent  to  the 
heart. 
Time,  synchronous  with   the  heart's  motion, 
and  accompanied  by  others  (coarser)  during 
respiration. 
Character,  usually  fine,  grazing. 
Bronchial  Hales  from  coexisting  bronchitis  (in- 
cidental). 
WHEN  THERE  IS  MODEMATE   EFFUSION— 
e.  g.,  at  the  level  of  the  fifth  rib  in  front,  not  suf- 
ficient to  markedly  displace  organs  or  change  con- 
tour of  the  thorax. 
INSPECTION. 

Posture  on  either  side  or  back. 
Hespiratory  Movement   limited    on    the  affected 
side,  now  due  in  part  to  compression  of  the  lung. 
Hyperpnma  and  perhaps  dyspnoea. 
PALPATION. 

Hestricted  Respiratory  Movements. 
Vocal  Fremitus  enfeebled  over  the  effusion. 
MENSURATION. 

Slight  loss  of  respiratory  expansion. 
PERCUSSION. 

Beginning  Dulness  over  the  fluid,  first  noticeable 

in  the  infra-scapular  and  infra-axillary  regions. 
Dulness  just  below  the  level  of  the  fluid  merging 

into  flatness  below. 
Elasticity  wanting  as  felt  by  the  pleximeter  finger. 
Upper  Line  of  Dulness  not  horizontal  in  the  erect 
posture,  but  highest  in  the  axillary  region,  de- 
scending in  front  and  behind,  forming  the  letter 
S  curve  posteriorly. 
Slight  Change  in  level  takes  place  slowly  in  change 
from  the  erect  posture  to  recumbency,  and  vice 
ve7'sd,  where  no  limiting  adhesion  exists  above 
the  effusion. 

10 


146  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

AUSCULTATION. 

Respiratory  Sounds  feeble  and  distant  or  absent 
over  the  fluid,  except  in  children,  where  they 
may  be  distinctly  broncho-vesicular. 
Immediately  Above  the  level  of  the  fluid  re- 
spiratory sounds  are  exaggerated  or  broncho- 
vesicular  and  harsh. 
Over  the  Sound  Lung*  Exaggerated  respiratory 
sounds  corresponding  to  increased  function. 
Vocal  Itesonance. 
Over  the  Fluid,  diminished  or  absent. 
At  the  Upper  Border  of  the  fluid  occasionally 

segophony  may  be  heard. 
Elsewhere  normal. 
WHEN      THE      EFFUSION      IS     LARGE      IN 
AMOUNT. 
INSPECTION. 

Posture,  usually  on  or  toward  the  afl^cted  side  to 

give  the  unobstructed  lung  free  play. 
Tailor,  from  anaemia,  and 

Emaciation  usually  present,  not  necessarily  marked. 
Cyanosis  of  the  lips,  chin,  end  of  nose,  and  tips 

of  extremities  not  infrequent. 
Unilateral  Enlargement  of  the  chest  on  the  af- 
fected side,  especially  the  lower  half. 
Nipple   and   Scapula    farther   from    the   median 

line. 
Shoulder  elevated. 
Lower  Intercostal  Spaces  widened  and  filled  out, 

rarely  bulging. 
Hypochondrium  prominent  on  the  afl'ected  side, 

especially  if  this  be  the  right. 
Hi/perjynwa,^  and  usually  dyspnoea,  very  marked 

on  slight  exertion. 
Mespiratory  Movements  markedly   restricted   on 
the  affected  side,  increased  on  the  sound  side. 


SIGN&  IN  THE  DISEASES  OF  THE  CHEST.         117 

Apex  Beat  displacjcd  to  the  riglit  or  left  away  from 
the  effusion. 
PALPATION  ill  large  pleuritic  effusion. 

Itesfi'icted  Movement  and   Enlargement  of  the 

affected  side. 
Intercostal  Spaces  widened  and  filled  out. 
A  Sense  of  Fltict nation    sometimes    obtained   by 
applying  the  finger  to  the  intercostal  spaces  and 
making  percussion  on  the  opposite  aspect  of  the 
affected  side. 
Vocal  Fremitus  absent  over  the  fluid,  except  in 
children,  where  it  may  be  present  over  effusions 
of    considerable    size.     It    may    be    conducted 
through  the  effusion  along  the  line  of  an  exten- 
sive adhesion  or  band.    Posteriorly  it  may  some- 
times be  conducted  for  some  distance  over  the 
effusion  from  the  sound  side  by  the  chest-wall  as 
a  medium. 
Apex  Beat  displaced. 

Pulse  accelerated,  small  in  volume,  low^  in  tension, 
especially  in  large  effusions  of  the  left  side.     It 
is  apt  to  be  irregular  in  both  time  and  force. 
Tender  Points  of  intercostal  neuralgia  not  infre- 
quently present. 
MENSURATION. 

Enlargefnent  and  loss  of  movement  on  the  affected 
side. 
PERCUSSION  in  large  pleuritic  effusion. 

Flatness  over  a  large  part  of  the  affected  side. 
In  the  Larg-est  Effusions  all  resonance  disap- 
pears except  over  a  limited  area  (dulness)  in 
the  upper  inter-scapular  region,  over  the  com- 
pressed lung.  Flatness  may  extend  across  the 
sternum,  encroaching  on  the  opposite  lung. 
In  Rig-ht-sided  Effusions  the  liver  dulness  is  de- 
pressed, sometimes  depressed  even  to  the  navel. 


148  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

In  Left-sided  Effusions  flatness  extends  to  the 

margin  of  the   ribs^  masking   the   spleen   or 

depressing  it  in  the  abdomen,  and  obliterating 

stomach  tympany  in  the  so-called  semilunar 

space  of  Traube. 

Vesiculo-tympanitie  note  may  be  present  in  the 

supra-scapular      and      supra-clavicular      region 

(Skoda).     This  is  owing  to  a  loss  of  pulmonary 

tension,  or  to  vesicular  emphysema,  or  possibly 

to  the  formation  of  vapor  in  the  pleuritic  space. 

Cracked-j)ot  resonance  sometimes  in  infra-clavicular 

region. 
Cardiac  Duhiess  may  be  found  to  the  right  of 
the  sternum. 
AUSCULTATION  in  large  pleuritic  effusion. 

Mesijlratory  and  vocal  sounds  wholly  absent  over 
the  affected  side,  except  feeble  bronchial  sounds 
in  the  inter-scapular  region  over  the  compressed 
lung.     These  are  absent  in  extreme  cases. 
Tfliisjyer  Resonance  sometimes  distinct  over  sero- 
fibrinous effusions,  but  absent  over  pus  (Baccelli). 
Position  of  Heart  can  frequently  be  made  out  by 
the  relative  distinctness  of  its  sounds,  when  its  im- 
pulse is  invisible  and  cardiac  dulness  uncertain. 
Systolic  Murmurs  may  be  heard  over  the  heart, 
which  disappear  after  aspiration  or  absorption 
of  the  effusion. 
AFTER    RESORPTION     OF     THE    EFFUSION 
when  the  effusion  has  been  long  present. 
INSPECTION. 

Affected  Side  shows — 

Circumscribed   Depressions    or   more  general 

retraction. 
Displacement  of  the  Intra-thoracic  organs  by 
retraction  of  the  lung  and  fibrous  pleuritic  ad- 
hesions. 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.         149 

Shoulder  lowered  on  the  affected  side. 
Intercostal  Spaces  narrow. 
Scapulae  may  project  in  a  wing-like  manner. 
Spinal  Column,  scoliosis  toward  the  sound  side. 

Sound  Side  shows  exaggerated  normal  condition. 
PALPATION. 

Apex  Beat  displaced. 

Vocal  Fremitus  exaggerated,  or  diminished  when 
the  main  bronchi  are  contracted  or  the  pleura 
is  greatly  thickened. 

Pulse,  normal  in  rate  and  force  where  the  contracted 
luncr  has  not  become  tubercular. 
PERCUSSION. 

Dulness  over  the  contracted  lung. 

Hyiyer-reso7iance  over  the  sound  lung,  which  may 
extend  across  the  mid-sternal  line  even  to  the 
parasternal  line. 
AUSCULTATION. 

Mesinratory  Sounds  diminished  on  the  affected 
side  and  more  or  less  bronchial.  On  the  sound 
side  respiratory  sounds  exaggerated,  or  dimin- 
ished and  vesicular  when  emphysema  has  devel- 
oped. 

PNEUMOTHORAX  and  PNEUMO-HYDROTHORAX. 
Definition  :  an  accumulation  of  air  or  other  gases  outside 
the  lung  in  the  pleural  cavity.  The  lung,  unless  bound 
by  adhesions,  retracts  and  finally  exists  as  a  collapsed, 
nearly  airless,  fleshy  mass  at  the  upper  and  back  part 
of  the  chest-cavity.  There  comes  to  be  more  or  less 
fluid,  serous  or  purulent,  at  the  lower  part  of  the  cavity 
(pneumo-hydrothorax  or  pneumo-pyothorax). 
Signs. 

INSPECTION^. 

PALLOR  and  EMACIATION  characteristic  of  advanced 
phthisis. 


150  PHYSICAL  PIAGNOSIS  OF  THE  CHEST. 

CYANOSIS  may  be  marked  when  perforation  oc- 
curs. 

E  N  LA  R  G  E  M  E  N  T  of  the  affected  side. 

INTERCOSTAL  SPACES  wide  and  full,  or  bulging, 
and  do  not  recede  on  inspiration. 

HYPERPNCEA  and  DYSPNOEA  amounting  to  ortho- 
pnoea,  especially  at  the  line  of  perforation.  These 
may  subside  except  on  exertion. 

RESPIRATORY  MOVEMENT  lost  on  the  affected  side, 
increased  on  the  sound  side. 

APEX  BEAT  displaced  usually  to  the  opposite  side  of 
the  chest. 
JPALPATIOJV, 

VOCAL  FREMITUS,  feeble  or  absent  over  the  aifected 
side. 

SUCCUSSIONFREMITUS  when  present,  characteristic 
of  pneumo-hydrothorax. 

PULSE  feeble  and  rapid. 
MEWS  UBA  TlOJSr, 

ENLARGEMENT  OF  THE  AFFECTED  SIDE. 
rEBCUSSION, 

OVER  THE  AIR  more  or  less  tympany,  varying  in 
pitch  according  to  the  amount  of  air  present  and 
the  degree  of  tension.  Amphoric  resonance  when 
a  large  opening  communicates  with  a  bronchus. 
When  the  air  is  under  great  tension,  as  in  cases 
where  the  opening  has  a  valve-like  action,  the  per- 
cussion note  may  be  positively  dull. 

OVER  THE  FLUID  flatness  at  the  lower  part  of  the 
chest  according  to  the  amount  present.  The  upper 
line  is  horizontal  and  straight,  and  changes  with 
the  posture  of  the  patient. 

OVER  THE  SOUND  SIDE  hyper-vesicular  resonance. 
AUSCULTATION. 

RESPIRATORY  and  VOCAL  SOUNDS. 
Over  the  Air  vesicular  murmur  absent. 


SIGNS  IN  THE  DISEASES  OF  THE  CHEST.  151 

Respiratory,  Vocal  and  Whisper  Sounds  wlioii 
present  are  amphoric,  l)at  may  be  feeble.  All 
respiratory  and  vocal  sounds  are  absent  if  the 
opening  into  a  bronchus  is  closed. 

Over  the  Fluid  they  are  absent. 

Over  the  Compressed  lAing,  at  the  upper  inter- 
scapular region.  Respiratory  and  \'ocal  sounds 
are  feeble,  but  bronchial  wlien  present  at  all. 

Over  the  Sound  Sidr  puerile  res])iration. 
ADVENTITIOUS  SOUNDS. 

Rales  when  present  over  the  aifected  side  are  me- 
tallic in  character. 

Metallie  Tinkling  when  fluid  drops  from  the  upper 
part  of  a  cavity  into  the  fluid  ;  it  may  also  be  due 
to  the  bubbling  of  air  through  the  fluid  when 
it  rises  above  the  mouth  of  the  opening  into  a 
bronchus. 

Suceussion  splashing  sounds,  upon  agitation  of  the 
fluid  by  shaking  the  body,  have  a  metallic  quality. 

Bell  or  Coin  Sound  is  produced  as  the  ear  is  ap- 
plied to  one  aspect  of  the  afi^ected  side  while  per- 
cussion is  made  by  two  coins  used  as  j^lexor  and 
pleximeter  (see  page  89). 

FALSE  PNEUMOTHORAX. 

Definition  :  the  term  has  been  applied  to  subdiaphragmatic 
air-containing  abscess  cavities,  usually  on  the  right  side, 
between  the  liver  and  diaphragm,  occasionally  on  the 
left.  They  originate  from  perforating  ulcers  in  the  wall 
of  the  stomach  or  duodenum. 

Signs  of  a  limited  pneumothorax  are  sometimes  present. 

DIAPHRAGMATIC   HERNIA  gives  signs  similar  to  those 
of  pneumothorax,  such  as 
Evidence  of  Displaced  Heart  and  compressed  lung. 
Tympanitic  Resonance. 


152  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Respiratory  Sounds  absent. 

Metallic  Tinkling  may  be  absent. 

Sudden  Disappearance  or  advent  of  signs  due  to  return 

of  the  bowel  to  the  abdominal  cavity  or  to  the  abnormal 

position. 
Borborygmi  characteristic. 

HYDROTHORAX. 

Definition  :  a  serous  transudate  (non-inflammatory)  into 
the  pleural  cavity.  It  is  usually  a  part  of  general 
dropsy,  but  may  occur  with  but  slight  oedema  of  the 
lower  extremities. 

In  renal  disease  and  anaemia  it  is  usually  bilateral. 
In  heart  disease  it  is  commonly  unilateral,  but  if 

bilateral  is  apt  to  be  unequal  on  the  two  sides. 
In  venous  obstruction  it  may  be  either  unilateral  or 

bilateral. 
Signs. 

INSPECTION  frequently  reveals 

CYANOSIS,  profuse  perspiration. 

EXPRESSION  of  anxiety. 

DYSPNCEA,  orthopnoea,  even  without  exertion  ;  respir- 
atory movements  limited. 

ABSENCE  OF  INFLAMMATORY  SIGNS. 
PALPATION  reveals 

NO  TENDERNESS  or  rise  of  temperature. 
PEBCUSSION  and  AUSCULTATION  demonstrate 

signs  of  unilateral   or  bilateral   effusion,  similar  to 

those  in  pleurisy,  without  the  presence  anywhere  of 

friction  sounds  or  other  evidences  of  inflammation. 

Hy^EMOTHORAX. 

Definition  :  an  effusion  of  blood  into  the  pleural  cavity 

as  distinguished  from  hemorrhagic  pleurisy. 
Signs  largely  those  of  hydrothorax,  with  evidence  in  the 
pallor  and  effect  on  the  circulation  of  considerable  loss 
of  blood. 


SIGNS  TN  THE  DISEASES  OF  THE  PERWAUDIUM.      153 

DISEASES  OF  THE   PERICARDIUM,   HEART, 
AND   GREAT    VESSELS. 

RARE  AFFECTIONS  OF  THE  PERICARDIUM,  essen- 
tially undemonstrable  during  life,  even  Avith  the  help  of 
history  and  symptomatology.     These  include 

Absence  or  Defects  of  the  Pericardium. 

Tumors,  Hydatids,  and  Syphilis  of  the  pericardium. 

PERICARDITIS. 

Definition  :  inflammation  of  the  pericardium. 
Signs. 

INSPECTIOm 

EXPRESSION  of  anxiety  common  ;  expression  of  pain 
upon  change  of  posture  or  deep  pressure  over  the 
heart. 

POSTURE,  usually  in  dorsal  semi-recumbency. 

VENOUS  distention  (ectasia)  in  the  neck  in  rare  cases 
where  effusion  makes  pressure  upon  the  superior 
vena  cava. 

PRECORDIAL  REGION  prominent. 

In  Children^  owing  to  the  pliancy  of  the  chest- 
wall.- 
In  Adttlts,  rare,  though  it  may  be  present  with 
effusion  of  12  to  15  ounces.     Potain  saw  it  with 
much  less. 

INTERCOSTAL  DEPRESSIONS,  may  be  obliterated, 
or  bulging  of  intercostal  spaces  may  be  present 
over  a  large  pericardiac  effusion  (paresis  of  the  in- 
tercostal muscles). 

BULGING  OF  EPIGASTRIUM  occasionally  present 
with  a  large  effusion,  though  it  does  not  occur 
early,  owing  to  the  ready  displacement  of  the  lungs 
before  much  lowering  of  the  diaphragm  is  effected. 

STUPOR,    DELIRIUM,   CONVULSIONS,   and   COMA 


154  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

may  occur  in  the  late  stage,  Avith  cardiac  failure 
and  venous  stagnation. 
DYSPNOEA  is  usually  present  both  early  and  late. 
APEX  BEAT. 

Forcible  and  rapid,  and  increased  in  area  in  the 

first  stage. 
WeaJi^  or  absent  in  recumbency,  but  may,  in  the 
presence  of  effusion,  become  both  visible  and  pal- 
pable in  forward  inclination  of  the  body,  as  in  the 
knee-elbow  posture.  Weakness  of  the  apex  beat 
may  also  be  due  to  simple  weakening  of  the  car- 
diac muscle,  usually  late. 
PALPATION, 

PULSE  not  necessarily  affected,  except  in  rate,  even 
when  the  heart  is  under  considerable  pressure  from 
effusion. 
APEX   BEAT  elevated  apparently,  and  changed  with 

posture. 
FRICTION  FREMITUS  common  in  the  early  stage. 
PEJRCUSSION, 

IN  THE  FIRST  STAGE  negative. 
IN  THE  SECOND  STAGE, 

Dulness   corresponds    largely  to    the   amount   of 
effusion. 
Early,  it  is  usually  first  to  be  detected  at  the 
base  of  the  heart  in  the  second  interspace,  and 
to  the  right  of  the  sternum  in  the  fifth  inter- 
space (this  is  a  very  important  sign).    A  quan- 
tity of  fluid  less  than  four  ounces  may  not  be 
recognizable. 
Later,  dulness  extends  to  the  left  of  the  apex  beat. 
In  laege  effu>sions  flatness  and  dulness  occur 
in  a  triangular  area,  with  its  apex  extending 
above  the  base  of  the  heart,  the  base  below, 
and  extending  far  to  the  right  of  the  sternum 
and   to   the    left  of   the  mammillary  line. 


SIGNS  IN  THE  DISEASES  OF  THE  I'ERICARDIUM,      155 

Dulness  in  recumbency  becomes  much  in- 
creased in  area  in  the  upright  posture,  and 
may   cause    bulging   of    intercostal    spaces 
which  before  were  sunken. 
A  use  UL  TA  TIOX, 
FRICTION  SOUNDS. 

Time  synchronous  with  cardiac  movements  ^^too 
and  fro,"  systolic  and  diastolic.  They  may  at 
times  disappear  for  a  few  beats  and  return. 
They  occur  independent  of  respiration,  but 
may  be  somewhat  influenced  by  respiration. 
They  may  be  present  for  the  first  few  hours, 
or  may  last  during  the  greater  part  of  the 
disease,  and  reappear  after  resorption  of  the 
effusion. 
Sedtf  over  the  precordia,  usually  first  heard  over 
the  base,  but  may  be  loudest  at  the  apex  or  over 
the  right  ventricle. 
Chxiracter. 

Quality,  grazing,  rough,  harsh,  or  soft,  and  at 

times  squeaking. 
Intensity  variable,  may  be  heard  at  a  distance 
from  the  chest,  may  be  increased  by  pressure 
of  the  stethoscope  or  by  exercise,  and  may  be 
influenced  by  respiration. 
Duration :  they  disappear  with  the  occurrence 

of  effusion  or  adhesion. 
Propag-ation :  they  are  feebly  transmitted,  and 
are  usually  confined  to  the  precordia. 
HEART  SOUNDS. 

Early,  normal  but  rapid. 

Later,  weakened,  with  the  occurrence  of  a  large 
effusion,  which  at  first  muffles  them  and  later 
weakens  them  by  weakening  the  heart  muscle. 
Arrhythmia  may  occur  with  weakening  of  the 
heart  muscle  by  pressure  or  adhesions. 


156  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

RESPIRATORY  SOUNDS. 

Bronchial  breathing  may  be  developed  over  lung 
adjacent  to  and  compressed  by  the  effusion.  It 
may  disappear  with  change  of  posture  to  reap- 
pear over  other  parts. 

MEDIASTINO-PERICARDITIS. 

Definition  :  inflammation  leadings  to  adhesion  between 
the  parietal  layer  of  the  pericardium  at  the  base  and 
the  wall  of  the  chest  or  mediastinal  tissue.  In  such 
cases  the  two  layers  of  the  pericardium  are  apt  to  be  ad- 
herent. Fibrous  bands  or  adhesions  may  implicate  the 
great  vessels  at  the  base,  and  also  the  pleura  and 
diaphragm. 
Signs. 

INSPECTION  may  show— 

INTERCOSTAL  SPACES  retracted  wdth  each  systole. 
DYSPNCEA,   ARRHYTHMIA,  and  weakening  of  the 
apex  beat,  and  other  signs  of  pericarditis  may  be 
present. 
INSPIRATORY  SWELLING  OF  THE  JUGULARS  has 
been   noticed,  probably  from  compression  of  the 
innominate  vein  or  superior  vena  cava. 
PALPATION, 

PULSUS  PARADOXUS  has  been  noticed  in  some  cases 
(see  page  54).     Pulse  may  be  irregular. 
PERCUSSION. 

AREA  OF  CARDIAC  FLATNESS  may  be  increased, 
since  adhesion  of  the  pericardium  to  the  chest-wall 
prevents  expansion  of  the  lung  in  front  of  the  heart. 
AREA  OF  CARDIAC  DULNESS  may  be  increased  as 
an  indication  of  cardiac  enlargement  following  de- 
generation. 
AUSCULTATION. 

MURMURS,  systolic  aortic,  or  pulmonic,  most  marked 
on  inspiration,  may  be  heard  in  some  cases. 


SIGNS  TN  THE  DISEASES  OF  THE  PERICARDIUM.      157 

HYDRO-PERICARDIUM. 

Definition  :    Herons  transiidate  (iion-inflamraatory)  into 
the  pericardium,  usually  as  a  part  of  a  general  dropsy. 
Signs  similar  to  those  of  pericarditis  with  effusion,  minus 
the  features  dependent  upon  inflammation  and  pyrexia. 

Hy€:MO-PERICARDIUM. 

Definition  :    effusion    of    blood    into   the    pericardium, 

usually  sudden  onset,  with  local 
Sig'ns  similar  to  those  of  hydro-pericardium. 

PYO-PERICARDIUM. 

Definition  :  purulent  effusion  into  the  pericardium. 
Signs,  those  of  inflammatory  effusion. 

PNEUMO-PERICARDIUM. 

Definition  :  gas  in  the  pericardium.     Usually  it  is  ac- 
companied by  fluid  (pneumo-pyo-pericardium).     Onset 
usually  sudden. 
Signs. 

INSPECTIOm 

EXPRESSION  anxious  or  pained. 
CYANOSIS,  sudden  collapse.     This  may  be  due  to 
pressure  upon  the  great  vessels  at  the  base  of  the 
heart. 
PRECORDIAL   PROTRUSION  of  the  chest-wall  and 

bulging  of  the  intercostal  spaces. 
DYSPNCEA. 
PALPATION, 

PULSE  rapid,  weak,  small,  and  may  be  irregular. 
APEX  BEAT  absent,  or  may  become  visible  and  pal- 
pable upon  forward  inclination  of  the  body. 
PERCUSSION. 

TYMPANITIC  RESONANCE  over  the  air  in  the  upper 

part  of  the  cavity. 
FLATNESS  over  the  fluid.     The  relative  position  of 
these  changes  with  the  change  of  posture. 


158  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

A  USCULTATION, 

FRICTION  SOUNDS,  metallic  in  quality,  sometimes 
audible. 

METALLIC  TINKLING,  or  gurgling,  splashing,  churn- 
ing sounds,  metallic  in  quality,  sometimes  heard, 
even  by  the  patient  or  others. 

HEART  SOUNDS,  metallic  in  timbre. 

CONGENITAL  ANOMALIES   OF   THE  HEART  AND 
GREAT  VESSELS. 
Definition  :  the  heart  may  be 
TOO  SMALL  or 

TOO  LARGE,  or  may  occupy  various 
ABNORMAL  JPOSTTIONS. 
ITS  CA  VITIES  may  be  too  small  or  too  large,  or  may 

be  crossed  by  abnormal  bands ;  also 
THE  SEPTA  between  them  may  be  deficient,  or  foetal 

openings  may  remain  patulous. 
THE  AORTA  and  PULMONARY  ARTERY  may 
be  abnormally  small. 
Signs :  many  of  these  abnormalities  have  existed  during 
a  part  or  the  whole  life  without  discoverable  symptoms 
and  signs.     Usually  they  show  at  some  time  physical 
evidences,  of  which  the  following  are  the  chief: 
INSPECTION, 

CYANOSIS,  early  in  occurrence,  is  the  most  marked 
sign  of  congenital  cardiac  deformity,  though  its 
presence  is  not  diagnostic,  and  its  absence  does  not 
always  exclude  a  defect.  It  is  not  infrequently 
entirely  absent,  slight  in  amount,  or  late  in  de- 
velopment. Some  cases  of  congenital  cyanosis 
may  be  due  to  abnormality  of  the  pulmonary 
capillaries. 
FAULTY  DEVELOPMENT  OF  THE  BODY  is  a  natural 

eifect  of  a  defective  heart. 
PRECORDIAL  PROTRUSION  is  common. 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.        159 

ABNORMAL  CARDIAC  ACTION,  arrhythmia  and  the 

signs  of  (cardiac;  enhirgement. 
DYSPNOEA. 
PALP  A  TION. 

PRECORDIAL  THRILL  not  uncommon. 
A  UHCULTA  TION. 

MURMURS  may  indicate 

Pafiifous  Ductus  Arteriosus, 
Seat. 

P08TEKIORLY  in  the  left  interscapular  region 
at  the  level  of  the  third  and  fourth  dorsal 
vertebrae. 
Time,  systolic. 
Character. 
Intensity. 

Increased  on  inspiration. 
Diminished  on  expiration. 
Uniform  on  holding  the  breath. 
Patulous  Foramen  Ovale  (according  to  Sansom). 
Seat. 

Anteriorly  at  the  level  of  the  third  and 
fourth  costal  cartilages,  to  the  left  of  the 
sternum. 
Time,  systolic  and  presystolic  murmurs  present. 
Perforation   of    the    Inter-ventricular    Septum 
(according  to  Roger). 
Seat. 

Upper  third  of  the  precordial  space  about  the 
third  interspace. 
Character. 

Limited  area,  not  propagated,  unaffected  by 
respiration  or  posture. 

CARDIAC  ATROPHY. 

Definition  :  a  degenerative  loss  of  muscular  volume,  gen- 
erally as  a  result  of  arterio-sclerosis,  which,  however, 


160  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

usually  causes  cardiac  enlargement,  exceptionally  atrophy. 
It  accompanies  general  marasmus  from  disease  or  age, 
and  results  in  diminution  in  the  actual  size  of  the  heart, 
unless  dilatation  occurs. 
Signs. 

INSPECTION. 

GENERAL  signs  of  marasmus  and  poor  blood-supply. 
LOCAL. 

Apeoc  Beat  faint  or  absent,  even  under  emotional 
excitement,  which  tends  to  render  it  more  visible 
and  palpable. 
PALPATION. 

APEX  BEAT  and  PULSE  weak. 
PERCUSSION. 

CARDIAC   DULNESS  diminished  in  both  deep  and 
superficial  areas.     Allowance  must  be  made  for  the 
lung  in  all  cases. 
An  Enlarged  Heart  overlapped  by  lung  may  sliow 

but  little  dulness. 
Marked  Emjihysenia  may  obliterate  all  dulness 
of   the   heart   whether   of  normal    size   or   en- 
larged. 
Retraction  of  the  Lung  with  displacement  of  the 
heart    may    increase   relative   flatness  and  dul- 
ness. 
AUSCULTATION. 

HEART  SOUNDS  will  depend  upon  the  strength  of 
the  heart  muscle. 
First  Soundy  especially  weak  or  absent  at  the  apex. 
Second  Sound,  pulmonic  distinct,  aortic  apt  to  be 
weak. 

CARDIAC  HYPERTRpPHY. 

Definition  :  muscular  thickening  of  the  walls  of  one  or 
more  cavities  of  the  heart.  It  rarely  occurs  without 
some  degree  of  enlargement  (dilatation  of  the  cavities). 


SIGNS  IN   Tin:  DISEASES   OF   THE  HE  ART.  IHl 

Signs. 

INSPECTION. 

PROMINENCE  OF  THE  PRECORDIA  in  children. 
APEX  BEAT. 

Force  increased. 

Area  increased  ;  sometimes  movement  of  the  wliole 

precordia.     It  extends  to  the  left  of  normal. 
EpifjaMric  Pulsation  strong  in  hypertrophy  of  the 
right  ventricle. 
CAROTIDS  beat  forcibly. 
PALPATION  confirms  inspection. 
PULSE  regular,  full,  and  forcible. 
PERCUSSION. 

CARDIAC  DULNESS  increased  to  the  right  of  the 
sternum  in  hypertrophy  of  the  right  ventricle,  and 
markedly  to  the  left  of  normal  if  the  left  or  both 
ventricles  are  enlarged. 
CARDIAC  FLATNESS  increased  in  area  from  dis- 
placement of  the  lung. 
A  USCLLTA  TION. 

In  the  absence  of  valvular  lesions  the  heart  sounds 
are  apt  to  be  sharp,  loud,  and  often  peculiarly 
ringing. 

HYPERTROPHY  WITH  DILATATION  gives  more  pro- 
nounced evidences  of  enlargement,  but  the  signs  otherwise 
are  similar  as  long  as  hypertrophy  compensates. 


CARDIAC  DILATATION. 

Definition  :  abnormal  increase  in  the  size  of  one  or  more 
of  the  cavities  of  the  heart,  whether  the  walls  are  atten- 
uated or  normal. 
Sig-ns. 

INSPECTION  reveals — 

EVIDENCES  OF  POOR  CIRCULATION. 
11 


162  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

JUGULAR  VEIN  varicosed,  and  pulsating  with  marked 
dilatation  of  the  right  heart. 
-   APEX  BEAT  absent  or  very  weak  and  undulatory  in 
character^  with  no  definite  point  of  maximum  in- 
tensity. 
PALPATION, 

PULSE   and  APEX    BEAT  weak  and  rapid  and  fre- 
quently irregular. 
PERCUSSION  shows— 

DULNESS  and  flatness  increased. 
A  TJSCUL  TA  TION, 

HEART  SOUNDS  soft^  feeble,  apt  to  be  abrupt,  and 
frequently  of  equal  length. 
Second  Sound  may  be  inaudible  at  the  apex  and  the 
First  Sound  reduplicated. 
Arrhythmia  frequently  present. 
MURMURS  if  present  are  apt  to  be  of  slight  intensity. 

MYOCARDITIS. 

Definition  :  difl^use  or  circumscribed  inflammation  of  the 
wall  of  the  heart. 

Acute,  ending  in  suppuration,  resolution,  or  fibrosis. 

Chronic,  commonly  considered  as  including  various 
degenerations  which  are  prone  to  accompany  and  fol- 
low inflammation.  It  may  result  from  atheroma,  cal- 
cification, thrombosis,  or  embolism  of  the  coronary 
artery,  with  resulting  infarction,  which  may  be 
hemorrhagic,  anaemic,  or  infected.  The  chronic  form 
is  apt  to  accompany  pericarditis  or  endocarditis.  The 
eifect  in  some  cases  depends  upon  direct  local  work 
of  micro-organisms,  in  others  upon  toxins  or  toxal- 
bumins. 
Signs, 

SIGNS  OF  ACUTE  lIYOCAIiniTIS :  this  form  is 
present  typically  in  typhoid  fever,  and  also  may  be 
present  in   diphtheria,   scarlet   fever,    cerebro-spinal 


SJGJ^S  IN  THE  JJJi^EASES  OF  THE  HEART.         163 

meningitis,  variola,  erysipelas,    and    in    acute    endo- 
carditis and  pericarditis. 

In  addition  to  the  signs  of  these  diseases  a  few  or 
many  of  the  following  may  be  present : 
INSPECTION. 
JPalloi'. 

I>ys2}fKBa  and  Sighing  Respiration, 
Ape;r.  Beat  absent. 
PALPATION. 

Coldness  of  the  extremities. 

Pidse  feeble,  often  extremely  irregular  (arrhythmia). 
PERCUSSION. 

Cardiac  Dulness  normal  unless  dilatation  or  peri- 
cardial effusion  is  j^resent. 
AUSCULTATION. 
Ar7'hythniia. 
Tachycardia. 

Heart  Sounds  muffled.     They  are  apt  to  assume 
the  foetal  type. 
SIGNS  OF  CHRONIC  MYOCARDITIS. 
INSPECTION  and  PERCUSSION. 

The  signs  of  weak  heart  as  in  the  acute  form ;  also 
Cyanosis  and  (JEdenia  of  the  Eoctremities.     The 
signs  of  acute  febrile  disease  absent. 
PALPATION. 
Pulse  shows — 

Marked  Arrhythmia  present  early  and  frequently 

persistent,  but  little  influenced  by  drugs. 
Irritability  of  the  Heart  upon  slight  excitement 
or  exertion. 
AUSCULTATION. 

Heart  Sounds  muffled,  indistinct,  irregular. 
First  Sound  reduplicated  not  infrequently. 

CARDIAC    LIPOMATOSIS,  or   fatty  infiltration   of  the 
heart. 


164  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Definition:  an  accumulation  of  fat  upon  the  heart.    This 

is  usually  a  part  of  general  obesity,  although  it  may 

occur  occasionally  in  lean  persons. 

In  modeeate  amount  it  has  little  or  no  effect  upon 
the  heart's  function,  though  the  amount  consistent 
with  health  varies  with  age,  habits,  constitution,  etc. 

When  excessive,  and  deposits  take  place  not  only  on 
the  surface,  but  infiltration  occurs  between  the  muscle 
fibres,  the  result  is  hampering  of  the  heart's  action, 
and  finally  pressure-atrophy  with  true  fatty  degenera- 
tion, to  which  the  resulting  symptoms  and  signs  are  due. 

CARDIAC   FATTY   DEGENERATION. 

Definition  :  a  more  or  less  localized  or  disseminated  retro- 
gressive change  of  the  muscular  fibres  of  the  heart  into 
fat,  almost  without  exception  associated  with  hyaline 
and  fibroid  degeneration. 
Signs  :  these  become  evident  only  when  degeneration  has 
become  sufficient  to  cause  dilatation  from  weakening  of 
the  muscular  wall. 
INSPECTION  may  reveal 

ARCUS  SENILIS  and  other  signs  of  age. 
VENOUS  STASIS  and  evidence  of  insufficient  blood- 
supply  to  the  organs. 
CEDEMA  of  the  extremities  is  present  in  the  late 

stage. 
DYSPNOEA  may  be  pronounced  on  slight  exertion. 
PALBATION 

PULSE  feeble,  especially  when  the  arm  is  held  high. 
It  is  frequently  irregular  in  both  time  and  force, 
and  may  be  slow.     In  a  late  stage  it  is  always 
rapid. 
FEMCUSSION. 

CARDIAC  DULNESS,  superficial  and  deep,  increased. 
A  USCULTA  TION, 

HEART  SOUNDS  weak,  and  are  apt  to  be  modified 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.        IGo 

and  obscured  by  relative  imiriniirs  (dependent  u[)(jn 
dilatation). 
ARRHYTHMIA  and,  late,  delirium  cordis. 

RUPTURE  OF  THE  HEART,  traumatic  or  non-traumatic. 
Non-traumatic  or  spontaneous  rupture  of  the  heart  occurs 
suddenly  in  case  of  degenerative  changes,  the  weakened 
heart-wall  being  subjected  to  some  sudden  strain  whether 
from  mental  or  physical  cause.     It  may  occur  in  such  a 
heart  during  perfect  tranquillity  of  mind  and  body. 
The  Signs  obtainable  are  but  few,  owing  to  the  sudden- 
ness of  the  accident.     The  person  may,  with  or  without 
an  outcry,  fall  at  once  into  collapse,  or,  as  occurs  not 
infrequently,  live  several  hours,  manifesting 
CYANOSIS,    COLD   SWEATS,    DYSPNCEA,  with, 
perhaps,  convulsions  and  coma.    In  other  cases,  where 
the  rupture  is  at  first  small,  there  may  be  attacks  of 
nausea,  vomiting,  anxiety,  vertigo,  syncope,  with  or 
without  evidence  of  anginal  pain. 

SYPHILIS  OF  THE  HEART  may  show  no  signs,  and 
when  present  they  do  not  diifer  from  those  of  myo- 
carditis and  degeneration  from  other  causes. 

ANEURYSM   OF  THE  HEART. 

Definition  :  though  cardiac  dilatation  is  in  so  far  a  species 
of  aneurysm,  the  term  is  limited  to  localized  attenuation 
of  the  wall,  acute  or  chronic,  with  circumscribed  dilata- 
tion which  may  be  distinctly  saccular. 

Signs  :  usually  neither  the  subjective  nor  objective  features 
are  distinctive,  and  the  disease  may  be  latent,  revealed 
only  by  autopsy  after  sudden  death,  otherwise  the  signs 
are  apt  to  be  those  of  myocarditis.     More  or  less 
CYANOSIS, 
DYSPNGEA, 
AMBHYTHMIA, 


166  PHYSICAL  DIAGNOSIS   OF  THE  CHEST. 

TACHYCABDTA  and  other  .signs  of  weak  heart.  Ex- 
ceptionally there  is  evidence  of  pulsating  tumor  and 
increase  of  cardiac  dulness. 

DIASTOLIC  MIBMUMS  have  been  heard,  probably 
due  to  the  regurgitation  of  blood  from  the  aneurysmal 
sac. 

THROMBOSIS  OF  THE  HEART  (ante-mortem). 

Definition  :  formation  of  a  clot  within  the  cavities  of  the 
heart.  This  is  usually  adherent  to  its  walls,  and  some- 
what firmly  enmeshed  among  its  tendinous  and  mus- 
cular bands,  but  it  may  form  polypoid  structures  or  non- 
adherent floating  masses. 

Two  FACTORS  usually  combine  to  its  occurrence  : 
A  retarded  circulation. 

A  toxic  condition  of  the  blood  or  local  diseased  foci 

upon  the  wall  of  the  heart. 

Signs :    the   process   may  not   be   apparent  during  life. 

When  the  coagula  interfere  with  the  valves,  or  detached 

masses  form  emboli,  the  symptoms  and  signs  may  vary 

widely.     The  diagnosis  is  usually  impossible. 

TUMORS  OF  THE  HEART. 

Carcinoma  usually  secondary,  by  extension  from  neigh- 
boring structures. 

Sarcoma  more  rare. 

Myomata  and  Fibromata  occasional. 
SIGJVS  very  uncertain. 

PARASITES,  such  as  Cysticercus  and  Echinococcus, 
are  relatively  rare,  and  their  diagnosis  usually  impossible, 
except  from  their  recognition  in  other  organs  and  the 
presence  of  cardiac  disturbance  of  more  or  less  gravity. 

NEUROSES  OF  THE  HEART.  The  so-called  cardiac 
neuroses  do  not  j)roperly  claim  notice  here. 


SIa^'s  js  TUK  diskasks  of  tjif  hi: art.       jgv 

Angina  PECToras  and  Palpitation  are  siilyective. 
Bradycardia  and  Tachycardia  and  Arrhythmia 
are  considered  under  the  pulse. 

ACUTE   ENDOCARDITIS. 

Definition  :   inflammation  of  the  endocardium  largely  con- 
fined to  the  valves.     It  may  be 

Simple,  characterized  by  the  growth  upon  the  valves 
of  vegetations  of  granulation  tissue,  capped  with 
fibrin  and  accom])anied  by  subendothelial,  small- 
celled  infiltrati(jn.  The  tendency  of  this  is  to 
resolution  by  absorption  of  tlie  vegetation  with 
nodular  thickening  and  contraction. 
Malignant  or  ulcerative  endocarditis  is  marked  by 
connective  tissue  vegetative  proliferation,  accom- 
panied by  necrosis  with  ulceration  or  suppuration. 
In  either  case  the  vegetations  may  be  carried  away 
as  emboli,  to  form  corresponding  simple  or  infective 
infarcts. 
Signs. 

,S  JOJV^  OF  SIMPLE  ENDOCARDITIS :  these,  apart 
from  the  symptoms  and  history,  are  not  characteristic. 
Many  cases  are  latent,  with  but  little  or  no  evidence 
of  cardiac  trouble.     When  the  disease  is  confined  to 
the  wall  of  the  heart  (not  involving  the  valves)  signs 
are  usually  absent. 
In  addition  to  the  evidences  of  the  primary  disease 
INSPECTION  may  reveal — 
Facial  anxiety. 

Apex  Beat  is  apt  to  be  increased  in  force  and  area 
in  the  beginning. 
PALPATION  elicits— 

Pid.se  full,  l)ounding,  and  perhaps  irregular. 
PERCUSSION  negative  in  uncomplicated  cases. 
AUSCULTATION  may  be  negative,  even  with  marked 
lesions  ;  but  a  soft 


168  PHYSICAL  DIAONOStS  OF  THE  CHEST. 

Systolic  llnrmuvy  usually  at  the  apex,  is  common. 
Heduplication    of    the    Second    Sound    may    be 

present. 
SIGNS  IN  ULCERATIVE  ENDOCAMDITIS. 
NOT  DISTINCT  apart  from  the  septic  or  typhoid 
manifestations  which  are  usually  present  as  a  part 
of  the  causative  affection.  In  such  cases  the  pres- 
ence of  endocardial  murmiirs  with  other  signs  of 
valvular  disease,  and  the  evidences  of  embolic 
processes,  point  strongly  to  the  diseases  in  question. 

CHRONIC  ENDOCARDITIS. 

Definition  :  it  is  essentially  a  sclerosis  of  the  valves  which 
produces  deformity  with  more  or  less  consequent  ob- 
struction or  incompetence. 
Signs :  when  the  disease  is  confined  to  the  wall  of  the 
heart  (rare)  it  may  show  no    signs.      Even  valvular 
disease  may  not  be  recognizable  by  signs  during  life. 
INSPECTION  may  disclose  more  or  less  of  the  fol- 
lowing : 
ANXIETY. 

CYANOSIS  of  the  prolabia  and  of  the  nose,  chin, 
cheeks,  and  tips  of  the  ears  is  common  in  mitral 
regurgitation  ;  marked  when  incompetence  occurs. 
PALLOR  of  the  face,  especially  in  aortic  and  mitral 

obstruction. 
ICTERUS  common,  and  may  be  extreme,  in  case  of 

secondary  duodenal  catarrh. 
CEDE  MA  of  the  extremities,  progressing  upward   in 

case  of  cardiac  weakness. 
PRECORDIAL  PROMINENCE  sometimes  present  in 

children  with  cardiac  enlargement. 
APEX  BEAT. 

Position :  displaced  to  the  left  and  downward. 
Strength:  weak  and  invisible    in  dilatation;    im- 
moderately strong  in  hypertrophy. 


SIGNS  JN  THE  DISEASES  OF    THE  HEART.         lOtJ 

CAROTIDS  show  excessive  beating  in   hypertrophy 
and  in  aortic  regurgitation. 

JUGULAR  PULSE  is  present  in  marked  tricuspid  re- 
gurgitation. 

DYSPNCEA  on  exertion  amounting  to  orthopna'a  in 
advanced  cases. 
rALrATIOX. 

APEX   BEAT  displaced  with  enlargement  of  the  ven- 
tricles. 

PULSE. 

(Joinpresaihle,  weak  and  small  in  cardiac  incom- 
petence and  frequently  irregular. 
Full,  bounding,  powerful  in  hy])ertrophy. 
Diastolic  Collapsing,  in  aortic  regurgitation. 
Small,  ff'h'i/  in  aortic  obstruction. 

FREMITUS,  or  thrills,  correspond  to  the  seat  of  the 
murmur.  Most  frequent  in  mitral  obstruction,  pre- 
systolic, at  the  apex ;  less  frequently  in  aortic  ob- 
struction, at  the  base  ;  rarely  with  regurgitant  mur- 
murs ;  common  over  the  subclavians  and  carotids  (sys- 
tolic) in  aortic  regurgitation.  (See  Fremitus,  p.  59.) 
rEBCUSSIOJ^. 

OUTLI N  E  OF  TH  E  H  EART  is  extended  to  the  left  and 
right  in  enlargement  of  the  organ,  according  to  the 
cavities  affected.  Often  it  is  difficult,  sometimes 
impossible,  to  make  out  by  percussion  the  actual 
size.  Evidence  of  enlargement  is  an  imj^ortant 
sign  in  differentiating  from  functional  murmurs. 
A  use  UL  TA  TIOK. 

THE  HEART  SOUNDS  may  be 
Iteplaced  by  murmurs. 

Modified  in  character,  muffled,  accentuated,  or 
Reduplicated,  or  otherwise  more  or  less 
fJhanged  in  Hhf/thm. 

MURMURS    usually   accompany    lesions.      (See   the 
various  Valvular  Lesions.) 


170  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

QaaUttj. 

Obstructive  murmurs  usually  liarsli  and  high- 
pitched. 

Regurgitant  murmurs  apt  to  be  blowing  and 
soft.       Either   of   them   may  be   musical   or 
soft,  like   whispered   "  who/'   or  creaking  or 
grating. 
Intensity  and  Duration, 

Sometimes  Very  Faint  even  with  serious  lesions. 
All  murmurs  are  apt  to  become  weak  with 
weak  heart  action,  grave  lesions  being  in  such 
cases  not  infrequently  unaccompanied  by  mur- 
murs. Sometimes  indistinct  murmurs  become 
loud  or  of  changed  quality  and  pitch  after  ex- 
ercise or  the  administration  of  cardiac  tonics. 
In  tumultuous  action  of  the  heart,  especially 
with  arrhythmia,  all  sounds  may  be  confused, 
and  murmurs  only  become  audible  after  car- 
diac stimulation. 

Sometimes  Murmurs  are  so  Loud  as  to  be 
heard  at  a  distance  from  the  patient. 

Certain  Postures  may  intensify  or  bring  out  a 
murnnir.  Asoulay  recommends  dorsal  pos- 
ture, head  flexed,  chin  in  contact  with  the 
chest,  arms  elevated,  thighs  and  legs  flexed  on 
the  abdomen.  Sitting  or  Standing  posture 
may  intensify  murmurs. 

According  to  Gerhardt,  in  beginning  aortic  insiiflBciency 
a  murmur  which  may  be  absent  in  recumbency  may  be 
heard  in  the  upright  posture,  while  the  reverse  is  true  in 
beginning  mitral  insufficiency. 

PitcJi  varies  with  the  lesion,  and  the  tension  and 
rapidity  of  circulation.  It  is  of  value  in 
diflerentiating  between  two  murmurs  occur- 
ring at  the  same  time. 

TiTne  refers  to  the  relation  in  the  cardiac  cycle. 


SIa^'S  IN  THE  DISEASES  OE  THE  HEART.         171 

Systolic  refers  to  the  contraction  of  the  ventri- 
cles (the  auricles  being  ignored),  and  hence  con- 
comitant with  or  destroying  the  first  sound, 
and  witli  the  apex  beat  and  carotid  pulse. 
Indirect  or  Regurgitant. 

Mitral  and  Tricuspid. 
Direct  or  Obstructive. 
Aorfic  and  Pulmonic. 
Diastolic  refers  to  the  dilatation  of  the  ventri- 
cle, hence  not  with  first  sound,  apex  beat,  and 
carotid  pulse. 
Direct,  Obstructivp]. 

Mitral  and  Tricuspid,  occurring  in  the  latter 
part  of  diastole  just  before  systole  (hence 
presystolic). 
Indirect  or  Regurgitant. 

Aortic  and  Pidmonic,  occurring  in  the  first 
part  of  diastole,  taking  the  place  of  the  re- 
spective aortic  and  pulmonic  second  sound. 
Transmission  or  Diffusion. 

Extent :  the  murmur  of  aortic  regurgitation  may 
be  heard  very  widely  from  its  seat,  even  as 
low  as  the  femoral  vessels,  though  rarely.  A 
murmur  may  be  very  limited  in  diffusion,  as 
in  mitral  obstruction  (heard  only  about  the 
apex).  A  murmur  must  necessarily  be  loud 
to  be  well  transmitted. 
Medium  of  transmission. 
The  Vessels. 

The  Aorta  and  its  branches  transmit  the  mur- 
murs of  both  aortic  obstruction  and  re- 
gurgitation, which  are  therefore  frequently 
heard  above  the  base  of  the  heart  and 
posteriorly  along  the  left  side  of  the  ver- 
tebral column,  especially  above  the  fifth 
dorsal  vertebra. 


172  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

The  Pulmonary  Artery  carries  the  pulmonic 
obstructive  murmur  up  under  the  second 
left  interspace,  hence  it  is  not  widely  dif- 
fused. 
The  Sternum  and  Kibs. 

Loud  Aortic  Murmurs  are  frequently  trans- 
mitted down  the  sternum  owing  to  tlie 
comparative  pro:5^imity  of  the  vessel  to 
the  bone  over  it. 
Mitral  Systolie  Murmurs  are  transmitted  to' 
the  left   along  the  ribs  from  the  apex, 
which  strikes  the  chest-wall  at  the  time 
they  are  produced. 
The  Diaphragm  doubtless  transmits  the  mnr- 
mur  of  aortic  regurgitation.     The  murmur 
is  produced  during  diastole  while  the  left 
ventricle  is  in  most  intimate  contact  with 
the   diaphragm,   the   blood   being   directed 
downward  toward  it.    The  murmur  is  there- 
fore transmitted  along  the  diaphragm  to  its 
attachment  at  the  end  of  the  sternum,  and 
along  the  costal  arch  close  to  the  left  of  the 
sternum.     Here  it  is  frequently  heard  with 
greatest  intensity. 
The  Blood  Current  within  the  heart.     In 
general,  murmurs  are   transmitted  best  in 
the  direction  in  which  the  blood  is  flowing 
at  the  time  the  murmur  occurs. 
In  Mitral  Obstruction  the  murmur  is  carried 
into  the  ventricle  toward  the  apex  with 
the  blood-current.    It  is  not  usually  trans- 
mitted to  the  left,  because  the  apex  is  not 
in  contact  with  the  chest- wall  at  the  time. 
In  Mitral  Regurgitation  the  murmur  is  un- 
doubtedly carried  into  the  auricles  with 
the  blood,  as  may  be  verified   in    some 


SIGNf^  IN  THE  DISEASES  OF  THE  HEART.        173 
cases  where  this  lesion  is  complicated  by 

CONSOLIDATION      OP    THE     LUNG     at    the 

base  of  the  heart,  ^vhich  transmits  the 
murmur  to  the  surface  at  that  point,  or 
where  there  is  retraction  of  the  lung  un- 
covering the  auricle  anteriorly.  The 
normal  lung,  owing  to  the  oblique  posi- 
tion of  the  heart,  is  relatively  thick  over 
the  base,  and  does  not  transmit  the  mur- 
mur. 
Seat  of  a  murmur :  the  place  of  its  greatest  intensity. 
Valvular  Lesions. 

AORTIC  INSUFFICIENCY, 

DEFINITION  :    a  defect  of  the  aortic  valve,  allow- 
ing  regurgitation   into   the   left  ventricle   during 
diastole. 
SIGNS. 

Insjyection. 

Pace  usually  pale. 

Precordial  Reg-ion  is  apt  to  be  prominent  in 

children,  in  cases  of  long  standing. 
Apex  Beat. 

Area  enlarged,  reaching  to  the  left,  it  may  be 

even  to  the  mid-axillary  line.^ 
Force  of  impact,  increased  where  compensa- 
tion is  good,  sometimes  shaking  the  chest 
markedly  or  agitating  the  entire  trunk. 
Systolic  Retraction  of  an  intercostal  space 
over  the  apex,  occasionally  present.   It  may 
be  due  to  retraction  of  the  lung  and  action 
of  the  heart  in  systole. 
Carotids  and  other  arteries  pulsate  violently  and 

distinctly  collapse  in  diastole. 
Capillary  Pulse  (Quincke)  may  be  seen  in  a  line 
of  artificial  hypenemia  drawn  upon  the  sur- 
face, and  in  the  bed  of  the  finger-nails,  fundus 


174  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

of  the  eye,  and  in  the  mucous  membrane  when 
slightly  pressed  beneath  a  glass  slide. 

Rhythmical  Swelling"  of  the  Uvula  (Miiller) 
may  sometimes  be  seen. 

Faint  Venous  pulse  has  been  seen  in  the  hand 
and  arm  (Quincke) — rare. 
Palpation  reveals  also 

Apex  Beat  displaced,  area  enlarged,  and  force 
usually  increased. 

Fremitus. 

Diastolic  Thrill  is  rarely  felt  over  the  base 

of  the  heart  in  the  aortic  area. 
Systolic   Thrill   commonly  felt  over   the 
carotids  and  subclavian  arteries. 

Pulse :  "  water  hammer/^  '^  pistol/^  ^'  collapsing  " 
in  diastole.  When  the  wall  of  the  left  ven- 
tricle is  strong  the  pulse  is  full,  bounding,  and 
sudden  in  systole,  but  falls  away  from  the 
finger,  leaving  an  apparently  empty  artery,  in 
diastole.  This  is  especially  marked  when  the 
arm  is  held  high,  owing  to  the  eifect  of  gravity 
on  the  fall  of  blood  directly  toward  the  ven- 
tricle. Examine  the  arm  in  both  the  high 
and  low  positions  and  note  the  difference. 
Percussion. 

Cardiac  Dulness  over  an  increased  area,  de- 
fining the  border  of  the  heart  far  to  the  left 
of  the  nipple  line. 

Cardiac  Flatness  much  increased  in  area  from 
enlargement  of  the  heart  and  crowding  back 
of  the  lung  (see  p.  160). 

Dulness  may  be  marked  in  the  left  second  inter- 
space in  case  of  relative  aortic  insufficiency 
from  dilatation  of  the  aorta  at  its  beginning. 
Auscultation, 

Murmur. 


SIGNS  IN  THE  DISEASES  OE  THE  HEART.         175 

Time  :  diastolic,  with  or  obscuring  the  second 

sound. 
Seat  :  in  the  aortic  area,  second  right  inter- 
space, sometimes  over  the  sternum  at  this 
level,  occasionally  over  the  lower  end  of  the 
sternum  and  costal  arch  close  to  the  left, 
over  the  attachment  of  the  diaphragm.  In 
the  latter  case,  I  believe  the  nmrmur  is 
transmitted  along  the  diaphragm  (see  p.  172). 
Charactp:r. 

Quality  usually  somewhat  soft,  gushing,  or 
swishing.     Occasionally  rough  where  de- 
posits have  occurred  upon  the  valves.    It 
may  be  musical,  and  especially  is  it  apt 
to  be  so  in  relative  insufficiency  (Groedel). 
Intensity  and  pitch  variable.     It  is  usually 
loudest  with  large  openings  ;   sometimes 
loudest  with  the  arms   elevated.     Cases 
have  been  reported  where  the  murmur 
was  intermittent. 
Duration,  long. 
Propagation. 

Down  the  Sternum,  owing  to  the  proximity 

of  the  aorta  to  this  bone  over  it. 
Toivard  the  Apex,  down  the  left  ventricle. 
Along  the  Diaphragm  to  the  lower  part  of 
the  sternum  and  the  costal  arch  close  to 
the  left. 
Above  the  Base  of  the  heart,  along  the  ves- 
sels.    When  the  murmur  is  loud  it  may 
be  very  widely  disseminated,  even  to  the 
main  arteries  of  the  extremities  (rare). 
Associated  Murmurs. 

Aortic  Systolic  murmur  may  often  be  heard, 
though  insufficiency  more  frequently  ex- 
ists aloue  than  stenosis. 


176  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Mitral  Systolic  murmur  frequent  on  account 
of  relative  mitral  insufficiency  from  di- 
latation of  the  left  ventricle.  The 
murmur  of  aortic  insufficiency  may  be 
absent  where  there  is  a  marked  insuffi- 
ciency of  the  mitral  valve  (Timofejew 
and  Bolkin). 

Presystolie  Murmur  sometimes  heard  at  the 
base,  and  may  be  accompanied  by  a  frem- 
itus. 

The  cause  is  uncertain,  but  probably  it  is  due  to 
vibration  by  the  current  from  the  auricle  of  the 
larger  segment  of  the  mitral  valve,  previously 
floated  out  by  the  refluent  blood  from  the  aorta. 

Systolic  Murmurs  are  usually  heard  over  the 
carotids  and  subclavians  accompanied  by 
a  fremitus,  both  probably  due  to  the  sud- 
den systolic  filling  of  these  vessels,  which 
were  j^reviously  emptied  in  diastole.  Both 
murmur  and  thrill  over  a  subclavian  may 
disappear  when  the  arm  is  raised  above 
the  head. 

Double  Murmurs  (systolic  and  diastolic)  are 
sometimes  heard  over  the  larger  arteries, 
such  as  the  femoral. 
Heart  Sounds. 

Mitral  and  Tricuspid  first  sounds  intact  if 
the  corresponding  valves  are  competent. 

Aortic  Second  sound  destroyed. 

Pulmonic  Second  sound  normal  or  obscured 
by  the  loud  aortic  murmur.  It  is  only  ac- 
centuated with  disturbed  compensation,  re- 
sulting in  relative  mitral  insufficiency  and 
pulmonary  engorgement.  Tliis  accentua- 
tion disappears  with  failing  compensation 
of  the  right  ventricle. 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.         177 

A  on  TIC  OBS  TR  LCTI  ON. 

DEFINITION  :  a  defect  of  the  aortic  valve  interfering 
with  the  current  from  the  left  ventricle  into  the 
aorta. 
SIGNS. 

Ins2Jection, 

Face  is  apt  to  be  pale. 

Precordial  Reg-ion  may  be  prominent  where  car- 
diac enlargement  occurs  in  childhood. 
Apex  Beat  displaced  downward,  sometimes  to 
the   sixth    interspace    and   somewhat   to   the 
left. 
Area  and  force  variable. 

Carotids  and  other  arteries  show  but  little  pul- 
sation. 
PaljKition, 

Apex  Beat,  when  hypertrophy  is  good,  is  marked 

as  contrasted  with  the  small  pulse. 
Preraitus,  systolic  thrill  sometimes  felt  in  the 
aortic  area  in  pure  aortic  stenosis,  which  is 
rare. 
Pulse  tardy,   slow,  small,  and   sometimes   very 
hard  and  wiry. 
JPercussion. 

Cardiac   Dulness   increased  downward  and  to 
the  left. 
Auscultation, 
Murmur. 

Time,  systolic,  with  the  first  sound. 

Seat,  aortic  area. 

Character. 

Quality  apt  to  be  harsh,  strident,  sometimes 

whistling  or  hissing. 
Intensity  and  pitch  vary  in  different  cases. 
Duration  long,  o\ving  to  the  relatively  slow 
discharge  of  the  ventricle. 

12 


178  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Propagation. 

Above  the  Base,  into  the  carotids. 
Toward  the  Apex,  and  when  loud 
Doicn  the  Sternum. 
Associated  Murmurs. 

Aortic  Diastolic  murmur  is  usually  present, 
as  pure  stenosis  without  regurgitation  is  rare. 
Heart  Sounds. 

Mitral  and    Tricuspid  sounds  normal,  the 
former  often  peculiarly  loud,  unless  rela- 
tive mitral  insufficiency  exists  as  a  result 
of  dilatation  of  the  ventricle. 
Aortic  Second  sound  feeble. 
Pulmonic  Second,  normal  or  accentuated. 
MITRAL  INSUFFICIENCY. 

definition:  a  defect  of  the  mitral  valve  allowing 

regurgitation  into  the  left  auricle  daring  systole. 
SIGNS. 

liispection  reveals  but  little  abnormal,  while  com- 
pensation is  efficient,  except  the  signs  of  hyper- 
trophy in  greater  or  less  degree.     When  com- 
pensation fails,  the  visible   signs  are  cyanosis, 
oedema,  dyspnoea,  cough,  etc. 
Palpation  during  loss  of  compensation  may  reveal 
Pulse  weak,  small,  rapid,  and  more  or  less  irreg- 
ular. 
Apex  Beat  usually  to  the  left,  owing  to  enlarge- 
ment of  the  right  heart  and  slight  hypertrophy 
of  the  left  ventricle. 
Percussion  usually  shows  cardiac  enlargement  both 
to  the  right  and  left.     Dulness  may  be  found  as 
high  as  the  second  rib,  to  the  left  of  the  sternum, 
owing  to  enlargement  of  the  left  auricle. 
Auscultation. 
Murmur. 

Time,  systolic,  destroying  the  mitral  first  sound. 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.         179 
Seat  at  the  apex. 

Rarely  it  is  heard  with  great,  if  not  with  equal  inten- 
sity at  the  base,  about  two  inches  to  the  left  of  the  sternum. 
This  is  thought  (Naunyn)  to  be  due  to  the  propagation  of 
the  sound  with  the  blood  as  it  rushed  into  the  point 
of  the  ajjpendix  of  the  left  auricle,  which  in  some  cases, 
when  enlarged,  curves  around  and  lies  in  front  of  the 
pulmonary  artery. 

Character. 

Quality  usually  soft,  blowing,  like  the  whis- 
pered "  who,''  occasionally  rough,  musical, 
hissing,  or  rasping,  etc. 
Pitch  and  Intensity  variable. 
Duration:   it   may  last  up  to  the   second 
sound. 
Propagation  commonly  to  the  left  of  the 
apex,  and  when   loud  may  be  heard  pos- 
teriorly at  the  lower  angle  of  the  scapula ; 
it  is  not  usually  heard  at  the  base,  and  not 
above  the  base  nor  over  the  sternum. 
Heart  Sounds. 

Second  Pulmonic  sound  accentuated,  owing 
to  increased  tension  in  the  pulmonary  artery, 
but  the  accentuation  disappears  when  the 
compensatory  hypertrophy  of  the  right  ven- 
tricle fails. 
MITBAL  STENOSIS, 

DEFINITION  :   a  defect  of  the  mitral  valve,  inter- 
fering with  the  current  from  the  left  auricle  into 
the  ventricle. 
SIGNS. 

Inspection, 

Pallor  of  face  and 

Cyanosis,  more  or  less  marked  as  compensation 

fails. 
Epigastric  Pulsation  from  enlargement  of  the 
right  heart. 


180  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

Taljyation, 

Fremitus,  or  thrill,  presystolic,  not  infrequent  at 

the  apex. 
Pulse  apt  to  be  small  and  weak.     When  com- 
pensation fails  it  becomes  rapid  and  extremely 
arrhythmic  in  both  time  and  force. 
Percussion. 

Dulness  often  •  in  the  second  interspace  to  the 
left  of  the  sternum  over  the  dilated  auricle, 
and  dulness  also  evident  to  the  right  of  the 
sternum  and  to  the  left  of  the  normal  line 
when  enlargement  of  the  right  ventricle  is 
marked.  The  left  ventricle  enlarges  if  at  all 
by  atrophy  and  dilatation  from  poor  nutrition, 
but  no  hypertrophy  occurs  in  it. 
Ausciiltcition, 
Murmur. 

Time,  presystolic,  in  the  latter  part  of  diastole, 
ending  in  the  first  sound  or  in  a  systolic  re- 
gurgitant murmur,  which  frequently  is  asso- 
ciated with  it. 
Seat  at  the  apex,  sometimes  just  above  and 
slightly  to  the  left,  because  the  left  ven- 
tricle is  displaced,  backward  to  a  degree  and 
to  the  left,  by  the  greatly  enlarged  right  ven- 
tricle, which  in  this  case  gives  the  apex  beat. 
Chaeacter. 

Quality,  rough,  rumbling. 
Pitch,  Duration,  and  Intensity  variable.    It 
is  a  relatively  prolonged  murmur. 
Propagation   very   limited.     It   is   usually 
confined  to  a  small  area  at  the  apex,  and  is 
not  heard  far  to  the  right  or  left  or  at  the 
base. 
Associated  Murmurs. 

Mitral    Systolic    regurgitant    murmur   is 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.        181 

usually  present,  as  obstruetion  rarely  oeeurs 
without  producing  some  incompetence  of 
the  valve. 

Pulmonic  Diastolic  murmur  from  relative 
insufficiency  of  the  pulmonary  valve,  due  to 
continuous  high  pressure  in  the  pulmonary 
artery.  This  is  lieard  only  when  the  right 
ventricle  is  powerful,  and  may  be  absent 
when  there  is  relative  tricuspid  insufficiency. 

Tricuspid  Systolic  murmur  from  relative 
insufficiency  of  that  valve.  When  compen- 
sation of  the  right  ventricle  fails  the  heart 
becomes  extremely  rapid  and  irregular,  and 
the  sounds  and  murmurs  faint,  a  condition 
termed  delirium  cordis. 
Heart  Sounds. 

Mitral  first  sound,  when  not  destroyed  by  an 
accompanying  murmur  of  regurgitation,  is 
intact  and  seemingly  terminates  the  mur- 
mur. 

Tricuspid  first  sound  is  often  peculiarly 
loud. 

Pulmonic  second  sound  is  accentuated  in  case 
the  right  ventricle  is  hypertrophied.  Ac- 
centuation disappears  with  failing  compen- 
sation of  the  right  ventricle. 

Aortic  second  sound  is  apt  to  be  faint. 

Eeduplication  of  the  second  sound  is  fre- 
quent, probably  from  the  difference  in  ten- 
sion in  the  pulmonary  artery  and  aorta. 
PULMOJNAMY  INSUFFICIENCY. 

definition:  a  defect  of  the  pulmonary  valve  allow- 
ing regurgitation  into  the  right  ventricle  during 
diastole.  It  is  usually  congenital,  but  may  be  a 
part  of  a  general  endocarditis,  or  relative  from 
dilatation  of  the  pulmonary  artery  at  its  beginning. 


182  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

SIGNS. 

Inspection. 

Apex  Beat  displaced  to  the  left. 
Pulsation  frequently  visible  in  the 

Second  Left  Interspace.    Pulsation  of  the 
Right  Ventricle  between  the  ensiform  car- 
tilage and  costal  arch. 
PaliJation, 

Fremitus,  diastolic  thrill  over  the  second  left 

interspace,  occasional. 
Pulse,  generally  regular  but  not  large.     May  be 
variously  affected,  owing  to  the  lesions  of  other 
valves  usually  present. 
Percussion. 

Dulness  of  the  enlarged  right  ventricle  to  the 
right  and  left  of  the  sternum. 
Auscultation, 
Murmur. 

Time  diastolic,  replacing  the  second  pulmonic 

sound. 
Seat  at  the  base  in  the  second  interspace. 
Character  not  peculiar,  except  that  it  is  in- 
creased in  intensity  during  expiration  (Ger- 
hardt). 
Propagation  limited ;  not  transmitted  into 
the  cervical  vessels.     Being  usually  loud,  it 
may  be  heard  over  the  whole  heart,  distinct 
over  the  right  ventricle. 
Associated  Murmurs. 

Tricuspid  Systolic  murmur  from  relative 
insufficiency  is  apt  to  occur. 

At  a  distance  from  the  heart  may  occasionally  be 
heard  on  inspiration  an  interrupted  vesicular  respira- 
tion, possibly  due  to  pulmonary  capillary  pulse,  anal- 
ogous to  the  collapsing  capillary  pulse  of  aortic  re- 
gurgitation (Gerhardt). 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.         183 

Heart  Sounds. 

Mitral  and  Aortic  sounds  apt  to  be  weak. 
Pulmonic  Second  destroyed  by  the  murmur. 
Tricuspid  accentuated,  if  hypertrophy  of  the 
right  ventricle  be  adequate  and  no  relative 
insufficiency  of  the  tricuspid  valve  occurs. 
P  UL3IONA  R  Y  S  TEN  OS  IS, 

DEFINITION  :  a  defect  of  the  pulmonary  valve  in- 
terfering with  the  systolic  current  from  the  right 
ventricle.  It  is  among  the  very  rarest  of  acquired 
lesions,  but  most  frequent  of  the  congenital  valve 
lesions,  and  usually  associated  with  other  anomalies. 
SIGNS. 

Tiisj^eeflon  reveals  deranged  circulation  and  mal- 
formation and  general  arrest  of  development. 
Eyes  prominent ;  Lips  thick,  red. 
Superficial  Veins  enlarged. 
Cyanosis  often  extreme. 
Thorax  narroAv  and  precordia  prominent. 
Abdominal  Protrusion. 

Fing-er  Ends  clubbed,  blue  ;  nails  curved,  thick. 
Cardiac  Impulse  displaced  and  often  increased 

so  as  to  agitate  the  chest. 
Dyspnoea  common. 
JPaljKition, 

Fremitus  in  the  second  left  interspace. 
Apex  Beat  displaced. 
Pulse  weak. 

Surface,  and  especially  the  extremities,  cold. 
Percussion, 

Enlarg-ed  Right  Ventricle,  giving  dulness  to  the 
right  of  the  sternum. 
Atiscultation. 
Murmur. 

Time,  systolic,  with  the  first  sound. 
Seat,  second  left  interspace. 


184  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

TRICUSPID  INSUFFICIENCY. 

definition:  a  defect  of  the  tricuspid  valve  allow- 
ing regurgitation  into  the  right  auricle  during  sys- 
tole. Except  in  foetal  life,  it  is  usually  relative, 
consecutive  to  valve  lesions  which  have  caused 
dilatation  of  the  right  ventricle. 
SIGNS. 

Inspection. 

Face  is  apt  to  show  more  or  less  cyanosis.     In 
marked  insufficiency  of  long  standing  with  fail- 
ure of  compensation  there  is  marked  cyanosis 
with 
CEdema  of  the  extremities. 
Ectasia  of  the  superficial  vessels. 
Prominence  of  the  epigastric  and  right  hypo- 
chondriac regions  occurs  from  enlargement  of 
the  liver. 
Dyspnoea. 
Pulsation  of  the  right  ventricle  evident  at  the 

ensiform  cartilage  and  epigastrium. 
Jugular  Pulsation  present  in  well-marked  cases. 

The  venae  cavse  and  innominate  vein  have  no  valve,  but 
for  the  production  of  jugular  pulsation  this  vein  must  be 
sufficiently  dilated  to  overcome  the  valve  at  its  root,  which 
otherwise  long  resists  the  backward  pressure. 

Time,  systolic. 

Seat,  most  marked  on  the  right  side.  The  bulb 
of  the  jugular  first  pulsates.  Sometimes  it 
may  be  seen  just  above  the  clavicle  outside 
the  sterno-cleido-mastoid.  When  the  inter- 
nal jugular  pulsates  the  external  does  also. 

Intensity  :  it  only  occurs  with  a  relatively 
powerful  right  ventricle. 
Pressure  easily  obliterates  all  pulsation  above 

the  point  of  its  application. 
It  is  greatest  during  inspiration. 


SIGNS  IN  THE  DISEASES  OF  THE  HEART.  185 

Hepatic  Venous  Pulsation  is  better  felt  than 

seen. 
Femoral  Vein  may  pulsate  if  its  valve  (Eus- 
tachian) has  been  overcome  by  the  dilatation 
of  the  vessel. 
JPalpation. 

Apex  Beat  weak. 

Pulse  weak,  rapid,  unless  compensation  is  good. 
Hepatic  Venous  Pulsation   may  occur,  since 
these  veins  have  no  valves. 
Time,  systolic. 
Seat,  chiefly  in  the  left  lobe,  as  it  is  most 

easily  expanded. 
Intensity   and    character   like   that   of    an 
erectile  tumor. 
Percussion. 

Cardiac  Dulness  increased,  and  may  be  obtained 

well  to  the  right  of  the  sternum. 
Hepatic  Dulness  increased. 
Auscultation. 
Murmur, 

Time,  systolic,  taking  the  place  of  the  tricuspid 

first  sound. 
Seat  at  the  ensiform  cartilage  or  the  lower 

half  of  the  sternum. 
Chaeacter. 

Quality  usually  soft,  blowing. 
Intensity  and  pitch  not  peculiar.  The  mur- 
mur may  be  absent,  and  is  often  difficult 
to  make  out  in  the  presence  of  several  as- 
sociated murmurs.  It  is  commonly  over- 
looked. 
Propagation  distinct  to  the 

Right  of  the  Sternum,  sometimes  even  as  far 

as  the  axillary  line. 
Into    the  Jugular    Vein,   where    the    mur- 


186  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

mur  is  loud  and  the  venous  pulse  well 
marked. 
Associated  Murmurs  of  the  aortic  and  mitral 

valves  are  usually  present. 
Heart  Sounds. 

Mitral  sound  usually  destroyed  by  incom- 
petence of  the  valve. 
Tricuspid  sound  absent. 
Aortic  sound  may  be  present,  but  is  weak. 
Pulmonic  sound  weak  from  the  low  tension 
in  the  pulmonary  artery. 
TRICUSPID  STENOSIS, 

definition:  a  defect  of  the  tricuspid  valve  inter- 
fering with  the  presystolic  current  (auricular  sys- 
tole) into  the  right  ventricle.  It  is  exceedingly 
rare,  and  is  usually  of  foetal  origin. 
SIGNS :  it  is  generally  accompanied  by  other  con- 
genital lesions  which  mask  it. 
Inspection, 

The  signs  are  those  of  extreme  systemic  venous 
stasis. 
Palpation,  percussion,  and  auscultation  signs  not 
distinctive.     So  rare  is  this  affection  that  the 
characteristics  of  the  accompanying  murmur, 
if  present,  are  not  definitely  settled.     Hypo- 
thetical ly  it  has  been  described  as 
Time,  presystolic. 
Seat,  tricuspid  area. 
Propagation  limited  to  the  right  side  of  the  heart. 

FUNCTIONAL  ENDOCARDIAL  MURMURS. 

These  are  due  chiefly  to  aneemia  and  transient  causes, 
such  as  fever,  excitement,  etc. 
Time,  systolic ;  diastolic  murmurs  are  usually  organic. 
Seat,  usually  the  base  of  the  heart  in  the  pulmonary  area ; 

sometimes  the  aortic  area ;  occasionally  at  the  apex. 


SIGNS  IN  THE  DISEASES  OF  THE  AORTA.         187 

Character,  usually  soft,  blowing  in  quality. 
Propagation  very  limited. 
Associated  Signs  those  of 

ANjEMIA,  nervous  excitement. 

HEART  normal  in  size,  its  sounds  all  present,  though 
they  may  be  slightly  modified. 

ANEURYSM   OF  THE  AORTA  (THORACIC). 

Definition  :  a  fusiform  or  saccular  dilatation  of  the  aorta 
in  any  part  of  its  course,  above  the  diaphragm.    Its  en- 
largement causes  pressure,  disturbing   and  destructive 
to  neighboring  organs. 
Signs. 

INSPECTION  may  reveal 

AN  INFLAMED  AREA  of  reddened,  thin,  glazed  skin 
covering  the  site  of  the  aneurysm,  if  this  has  by 
pressure  come  sufficiently  near  the  surface. 
LIVIDITY  of  the  face,  neck,  and  upper  extremities 
from  pressure  upon  venous  trunks.     Lividity  and 
oedema,  when  sudden  in  occurrence,  may  be  due  to 
rupture  into  one  of  the  great  venous  trunks. 
TURGESCENCE  and  VARICOSITY  of  the  superficial 
veins  points  to  deep-seated  interference  with  venous 
trunks. 
EXPRESSION  :  the  eyeballs  may  become  prominent; 
expression  of  distress  may  indicate  the  more  or  less 
continuous  boring  pain  commonly  present. 
LOCALIZED  CEDE  MA  results  from  pressure  upon  the 
superior  vena  cava  or  innominate  vein.     It  may  be 
absent  from  establishment  of  collateral  circulation. 
Capillary  turgescence  may  produce 
A  THICK  FLESHY  COLLAR  at  the  base  of  the  neck, 
which  may  be  unilateral. 

These  pressure  signs  may  of  coarse  be  produced  by  other 
conditions,  such  as  tumors,  swellings,  inflammatory  contraction, 
thrombosis,  etc. 


188  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

INEQUALITY  OF  THE  PUPILS,  or  persistent  bilateral 
myosis,  may  result  from  pressure  upon  the  sym- 
pathetic nerve  trunks  or  branches.     Pupil  may  be 
contracted  on  the  affected  side. 
EMACIATION  and  ENFEEBLEMENT  progressive. 
ENLARGEMENT  or^BULGING  common  at  the   site 
of  the  aneurysm  ;  variable  in  size. 
Site. 

None  Present  when  the  Aneurysm  is  located 
at  the  Valves  of  Valsalva.     The  signs  in 
this  case  are  apt  to  be  obscure. 
Bulg-ing"  to  the  Right  of  the  Sternum  in  the 
second  interspace,  sometimes  extending  far  into 
the  infra-clavicular  and   mammary  region,  is 
apt  to  occur  from  aneurysm  of  the  ascending 
portion,  if  large.     More  rarely  it  appears  to 
the  left  of  the   sternum   at  a  corresponding 
level.     The  sternum  may  be  perforated. 
Bulging"  at  the  Upper  Part  of  the  Sternum 
and   adjacent   infra-clavicular    region   results 
from  aneurysm  of  the  transverse  portion. 
Bulging   Posteriorly,   below  the   level    of  the 
fourth  rib,  to  the  left  of  the  vertebral  column, 
may   result   from   aneurysm    of  the  thoracic 
aorta.     Very  rarely  it  appears  to  the  right  of 
the  vertebral  column.     Frequently  there  is  an 
absence  of  a  tumor. 
PULSATION,  if  visible,  at  the  site  of  an  aneurysm. 
Time,  systolic  (with  apex  beat). 
Character f  expansile  in  all  directions,  not  simply 
lifting  as  from  a  tumor  lying  upon  a  large  artery. 
Intensity :  to  detect  slight  pulsation  the  light  must 
be  good.    It  may  sometimes  be  detected  by  look- 
ing across  the  surface. 

Divergence  of  two  projecting  objects  with  each  pulsation 
may  reveal  an  otherwise  slight  expansion — e.  g.  stick  upon 


SIGNS  AY  THE  DISEASES  OF  THE  AORTA.         189 

the  surface  over  the  suspected  part  two  small  strips  of  paper, 
so  that  they  may  project  several  inches  at  right  angles  from 
the  surface. 

DEFICIENT  MOVEMENT  in  the  arteries  of  the  left 
.side  may  be  seen,  especially  in  aneurysm  of  the 
transverse  part. 

PULSATION  OF  THE  CAROTIDS  may  be  exaggerated. 

APEX  BEAT  is  apt  to  be  displaced  d(jwnward  and 
somewhat  to  the  left  with  corresponding  dislocation 
of  the  heart. 

EPIGASTRIC  PULSATION  may  be  marked  with  en- 
largement of  the  right  heart  as  a  result  of  disturbed 
pulmonary  circuit. 

RESPIRATORY  MOVEMENT  may  be  deficient  or  ab- 
sent on  one  side,  usually  the  left,  from  pressure  on 
the  main  bronchus. 

DYSPNOEA  and  HYPERPNCEA,  amounting  to  ortho- 
pnoea,  may  be  present,  either  due  to  laryngeal  paresis 
or  to  interference  with  the  lungs,  trachea,  or  bronchi 
(especially  in  aneurysm  of  the  transverse  portion). 

COUGH  a  frequent  sign  with  or  without  profuse  secre- 
tion, variable. 
PALPATIO^. 

AREA  OF  TENDERNESS  over  the  aneurysm  not  in- 
frequent, and  there  may  be  tender  points  charac- 
teristic of  intercostal  neuralgia. 

CONSISTENCE  of  the  tissue  over  an  aneurysm  may 
be  soft,  yielding,  and  even  fluctuating  when  cartilage 
and  bone  have  been  destroyed. 

THRILL  systolic  over  the  tumor  a  frequent  sign,  some- 
times very  early  obtained  by  pressure  of  the  fingers 
in  the  supra-sternal  notch. 

IMPULSE  obtained  over  the  tumor  usually 
Systolic, 

Diastolic  Shock  (usually  slight)  may  also  be  pres- 
ent, due  to  the  falling  back  of  an  unusual  volume 


190  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

of  blood  against  the  aortic  valve,  which  must  be 
competent  to  give  it.     (Diastolic  shock  absent  in 
insufficiency  of  the  aortic  valve.) 
RADIAL  and  CAROTID  pulse,  or  both,  may  be  un- 
equal in  volume  on  the  two  sides  owing  to  j)ressure 
on  the  innominate  artery  or  one  of  its  branches,  or 
to  obstruction  by  coagulum. 
THE    SUPERFICIAL   ARTERIES,   temporals,  radials 
frequently  show  rigidity,  inelasticity,  un evenness, 
or  tortuosity  as  a  part  of  general  atheroma. 
PULSATION  OF  THE  ABDOMINAL  ARTERY  and  its 
branches  may  be  very  weak  in  a  large  aneurysm  of 
the  descending  part  of  the  thoracic  aorta. 
TRACHEAL  TUGGING   is  sometimes  an  early  sign. 
Dr.  Wm.  Ewarts's  method  of  examination : 

Patient  seated,  head  thrown  back  against  exam- 
iner  as   he    stands   behind.     Trachea   gently 
stretched  by  pressure  made  with  tips  of  both 
index  fingers  placed  under  the  lower  edge  of 
the  cricoid  cartilage.     Sensation  of  traction  or 
tugging  downward  is  felt  with  each  heart-beat. 
VOCAL  FREMITUS  may  be  diminished  over  the  an- 
eurysm or  over  the  lung,  the  main  bronchus  of 
which  is  obstructed. 
PEMCUSSION  must  be  made  gently  in  case  of  sus- 
pected aneurysm  for  fear  of  causing  embolism. 
DULNESS  is  present  over  the  aneurysm. 
SENSATION    OF    RESISTANCE   to   the   pleximeter 
may  be  less  than  over  consolidated  lung  unless  the 
aneurysm  is  filled  with  fibrin. 
DULNESS   OVER   THE    LUNG   maybe  present  also 
when  the  main  bronchus  is  compressed  and  the  cor- 
responding lung  congested  or  collapsed.     Dulness 
over  a  part  of  the  lung  in  which  consolidation  is 
due  to  pressure  or  to  tuberculosis,  which  is  apt  to 
set  in  where  the  pulmonary  artery  is  compressed. 


SIGNS  IN  THE  DISEASES  OF  THE  AORTA.  191 

THE  HEART  is  not  usually  enlarged  when  the  aortic 
valve  is  unaffected,  but  it  may  be  displaced. 
A  use  UL  TA  TION,  _ 

MURMUR  is  present  in  about  half  the  cases.     Fre- 
quently  absent    in    saccular    aneurysm   (Douglas 

Powell). 

Systolic  Bruit  most  common.  In  some  cases  a 
murmur  may  only  be  detected  by  placing  the 
chest-piece  of  the  stethoscope  in  the  patient's 
mouth,  his  lips  being  closed  about  it  (Sansom). 
The  murmur  is  then  conveyed  by  the  trachea. 

Drummond,  of  New  Castle,  has  noted  a  systolic  murmur 
over  the  trachea,  possibly  due  to  expulsion  of  air  at  each 
distention  of  the  aneurysmal  sac  against  the  trachea. 

diastolic  Murmur  may  sometimes  be  heard  over 
a  saccular  aneurysm  independent  of  aortic  re- 
gurgitation, the  sepond  aortic  sound  of  the  heart 
being  clear  and  loud.  This  murmur  may  be  due 
to  the  elastic  recoil  of  the  wall  of  the  sac  forcing 
the  blood  back  into  the  aorta,  as  represented  in 
the  following  diagram  : 


Fig.  lO.-Illustrating  the  elastic  recoil  of  an  aneurysmal  sac,  producing  a 
diastolic  murmur. 

Diastolic  Murmur  of  Aortic  Insufficiency,  taking 
the  place  of  the  second  aortic  sound,  is  frequently 
present  in  aneurysm  involving  the  valves  of  Val- 
salva. 
VENOUS  HUM  in  the  neighborhood  of  the  aneurysm 
may  be  produced  by  pressure  against  a  large  vein 
or  perforation  into  the  vein.     It  is  continuous,  and 
apt  to  be  accentuated  with  each  systole. 


192  PHYSICAL  DIAGNOSIS  OF  THE  CHEST. 

SECOND  AORTIC  SOUND  is  frequently  accen- 
tuated and  of  a  ringing,  drumming,  or  clanging 
character,  unless  replaced  by  the  murmur  of  in- 
sufficiency. 
RESPIRATORY  AND  WHISPER  AND  VOCAL  sounds 
may  be 
Bronchial  over  a  compressed  lung  or  over  the 

aneurysm  when  resting  upon  the  trachea. 
Diminished  or  Absent  over  a  whole  lung  when 
the  main  bronchus  is  compressed. 
Forced  Inspiration  may  in  such  cases  give  dis- 
tinct respiratory  sounds,  absent  on  ordinary 
respiration. 

COARCTATION  OF  THE  AORTA. 

Definition  :  a  contraction  or  partial  stenosis  of  the  aorta 

(rare). 
Signs. 

INSPECTION  VQ\Q?X^  evidence  of  cardiac  hypertrophy, 
dilatation  of  the  arch  of  the  aorta  and  carotid  and 
subclavian  arteries,  and  dilatation  and  tortuosity  of 
the  superficial  arteries. 
rALPATION 

FEEBLE  PULSATION  in  the  abdominal  aorta  and  in 

the  arteries  of  the  lower  extremities. 
FREMITUS  over  the  large  arteries  of  the  head,  neck, 
and  upper  extremities. 
rERCUSSION  negative. 
AUSCULTATION. 
MURMUR. 

Quality  harsh. 
Pitch  high. 

Intensity  usually  loud. 
Time,  systolic  or  diastolic  (post-systolic). 
Proj)agation  into  the  subclavian  and  carotid  ar- 
teries, and  it  may  be  heard  posteriorly. 


SIGNS  IN  THE  DISEASES  OF  THE  ARTERIES.      193 

ANEURYSM   OF  THE   PULMONARY   ARTERY. 
Very  rare,  and  difficult  of  diagnosis,  even  with  the  aid  of 

subjective  manifestations. 
Signs  which  have  been  obtained. 
INSPECTION. 
CYANOSIS  marked. 
DROPSY. 

DYSPNCEA  pronounced. 
PULSATING  swelling  limited  to  the  second  interspace 
to  the  left  of  the  sternum,  where  aneurysms  of  the 
ascending  aorta  are  not  as  likely  to  present  as  those 
of  the  descending  aorta,   which  commonly  present 
posteriorly. 
PALPATION,  systolic  thrill. 
AUSCUL  TA  TION. 

MURMUR,  systolic  or  diastolic,  and  not  propagated 
above  the  clavicle. 

ANEURYSM   OF  THE   INNOMINATE  ARTERY. 
Signs  diffi9r  from  those  of  aortic  aneurysm  in 

LOCATION :  it  presents  to  the  right  of  the  sternum, 
in  the  region  of  the  inner  end  of  the  clavicle. 

PRESSUBE  signs  referable  to  the  recurrent  laryngeal 
nerve,  oesophagus,  and  trachea  are  not  so  apt  to  occur 
as  in  aortic  aneurysm. 

COMPMESSION,  by  the  examiner,  of  the  carotid  and 
subclavian  arteries  diminishes  the  pulsation  of  aneur- 
ysm of  the  innominate  artery,  but  does  not  affect  aortic 
aneurysm  appreciably. 


13 


INDEX. 


Adventitious  sounds,  85 
^gophony,  82 
Alar  chest,  36 
Amphoric  breathing,  75 

cough,  84 

resonance,  68 

whisper,  83 
Aneurysm  of  the  innominate  ar- 
tery, 193 

pulmonary  artery,  193 
Angle  of  Lewis,  32 
Aorta,  aneurysm  of  the,  187 

coarctation  of  the,  192 

landmarks  of  the,  30 

sounds  over  the,  108,  109 
Aortic  insufficiency,  173 

obstruction,  117 

pulsation,  46 
in  the  epigastrium,  50 

valves,  29 
Apex  beat,  28,  47 

in  emphysema,  121 
Apneumatosis,  123 
Apnoea,  41 
Arterial  movements,  45 

sounds,  108,  109 
Asphyxia,  41 
Asthma,  signs  of,  119 
Atelectasis,  123 
Atrophy,  cardiac,  159 
Auscultation,  70,  72 
Axillary  lines,  23 


Barrel-shaped  chest,  36,  121 

Bell  sound,  89 

Blood  currents  and  murmurs,  172 

Bone  resonance,  65 

Bradycardia,  55 

Breathing,  abnormal,  40 

amphoric,  76 

bronchial,  74 

broncho-cavernous,  75 

cavernous,  75 

cog-wheel,  78 

exaggerated,  puerile,  76 

feeble,  77 

interrupted,  78 

laryngeal,  74 

metamorphosing,  75 

normal,  59 
vesicular,  75 

rapidity  of,  40 

suppressed,  77 

vesiculo-cavernous,  75 
Bronchial  hemorrhage,  137 
Bronchiectasis,  117 
Bronchi,  diseases  of^  114 

primary,  28 
Bronchitis,  114-117 
Bronchophony,  81 
Broncho-pneumonia,  128 
Bruit  de  diable,  110 

Capillary  bronchitis,  116 
pulse,  46,  173 

195 


196 


INDEX. 


Cardiac  atrophy,  159 

dilatation,  161 

diseases,  153 

dulness,  29,  160 

fatty  degeneration,  164 

flatness,  29 

fremitus,  58 

hypertrophy,  160 

lipomatosis,  163 

movements,  47 

rupture,  165 

sounds,  89 
modified,  91 
Carotids,  pulsation  of,  46 
Cavernous  breathing,  75 

cough,  84 

whisper,  83 
Cavity,   cracked-metal  resonance 
in,  70 

in  pulmonary  tuberculosis,  131, 
134 
Cerebral  blowing,  108 
Chest,  form  of,  35 

size  of,  34 
Chest- wall,  diseases  of,  112 
Cheyne-Stokes  respiration,  42 
Cog-wheel  respiration,  78 
Collapsing  pulse,  174 
Color,  38 
Costal  arch,  20 

breathing,  39 
Cough,  varieties  of,  83,  84 
Cracked-metal  resonance,  70 
Crepitant  rtles,  84 

in  pneumonia,  128 
Crumpling  sounds,  87 

Diaphragm  and  murmurs,  172 
Diaphragmatic  breathing,  39 

hernia,  151 

pleurisy,  144 


Diastolic  murmurs,  102 

shock  in  aneurysm,  189 
Diseases  of  the  chest,  112 

heart,  153 

lungs,  143 

pericardium,  153 
Ductus  arteriosus,  patulous,  159 
Dulness,  cardiac,  29,  160 

hepatic,  30 

splenic,  31 

in  pulmonary  tuberculosis,  132 

pleurisy,  145 

pericarditis,  154 
Dyspncea,  40 

in  atelectasis,  123 

asthma,  119 

pneumonia,  125 

Emphysema,  pulmonary,  120 

of  the  chest- wall,  114 
Emphysematous  chest,  36,  121 
Empyema  pulsans,  49 
Endocardial  murmurs,  95 
Endocarditis,  167 
Enlarged  bronchial  glands,  142 
Epigastric  pulsation,  50 
Eupncea,  39 

Exocardial  murmurs,  94 
Expiratory  sound  prolonged,  79 

Fatty  heart,  163 
Fibroid  phthisis,  135 
Fissures  of  the  lungs,  25 
Flatness,  51 

cardiac,  29 

hepatic,  30 

in  pleurisy,  147 

splenic,  31 
Fontanelle,  sounds  over  the,  108 
Foramen  ovale,  patulous,  159 
Form  of  the  chest,  36 


INDEX. 


197 


Fremitus,  58-60,  169 
Friction  sounds,  88 

pericardiac,  94,  155 

pleuritic,  144 

pleuro-pericardiac,  94 
Friedreich's  change  of  sound,  69 
Functional  murmurs,  186 
Funnel  breast,  36 

Gerhardt's  change  of  sound,  69 

HiEMO-PERICARDIUM,  157 

Hsemothorax,  152 
Harrison's  groove,  37 
Heart,  aneurysm  of  the,  165 

congenital  anomalies  of  the,  158 

diseases  of  the,  153 

fatty,  163 

landmarks  of  the,  28 

neuroses  of  the,  166 

parasites  of  the,  166 

relation  to  the  lungs,  29 

rupture  of  the,  165 

sounds  (see  Cardiac),  89 

in  pulmonary  tuberculosis, 133 

syphilis  of  the,  165 

thrombosis  of  the,  166 

tumors  of  the,  166 

valves  of  the,  29 
Hepatic  dulness,  30 

flatness,  30 

venous  pulsation,  46 
Herpes  in  pneumonia,  125 
Hydatid  cysts  of  the  lung,  143 
Hydro-pericardium,  157 
Hydrothorax,  152 
Hyperpnoea,  40 
Hypopnoea,  41 

Innominate  artery,  aneurysm 
of  the,  193 
landmarks  of  the,  30 


Inspection,  33 
Inspiratory  sound,  79 
Intercostal  neuralgia,  112 
Interrupted  Wintrich's  change  of 

sound,  69 
Interval  in  respiration,  78 

Jugular  murmur.  111 
Jugulars,  inspiratory  swelling  of 
the,  156 
presystolic  pulsation  of  the,  45 

Landmarks  of  the  chest,  23 
Lines  of  reference,  23 
Liver,  landmarks  of  the,  30 

relation  to  the  lungs,  30 
Lobar  pneumonia,  124,  128 
Lungs,  diseases  of  the,  114 

fissures  of  the,  25 

landmarks  of  the,  24 

lobes  of  the,  26 

outline  of  the,  24 

relation  to  the  liver,  30 

Mammillary  lines,  23 
Mediastinum,  diseases  of  the,  114 
Mediastinal  pericarditis,  156 
!  Mensuration,  61 
Metallic  tinkling,  88 
Metamorphosing  breathing,  75 
Mitral  insufficiency,  178 

stenosis,  179 

valve,  30 
Movements,  39,  51 

cardiac,  47 

circulatory,  45 

respiratory,  39 
Murmurs,  aneurysmal,  191 

aortic  diastolic,  103 
systolic,  103 
j      cardiac,  94 
1      diastolic,  102 


198 


INDEX. 


Murmurs,  endocardial,  95 

exocardial,  94 

functional  endocardial,  186 

inorganic,  106 

mitral  diastolic,  103 
systolic,  96,  172 

non-valvular,  organic,  106 

pulmonic,  101 

transmission  of,  171 

tricuspid  diastolic,  104 
systolic,  100 
Myocarditis,  162 

Neuroses  of  the  heart,  166 
Normal  vesicular  breathing,  73 
dulness,  56 

Nutrition,  83 

Organic  murmurs,  96 
Orthopnoea,  42 

PALPATIO!^,  50 

Para-sternal  lines,  23 
Pectoriloquy,  whispering,  83 
Percussion,  61-63 
Pericardiac  friction  sounds,  94 

splashing  sounds,  94 
Pericarditis,  153 
Phonometry,  112 
Pigeon-breast  deformity,  36 
Pleurae,  diseases  of  the,  143 
Pleurisy,  cracked-metal  resonance 

in,  70 
Pleurodynia,  112 
Pleuro-pericardiac  friction  sounds, 

94,  144 
Plexor  and  pleximeter,  61 
Pneumo-hydrothorax,  149 
Pneumo-pericardiac  sounds,  95 
Pneumo-pericardium,  157 
Pneumothorax,  false,  151 
Posture,  37 


Posture  in  asthma,  119 

in  lobar  pneumonia,  124 

in  pleurisy,  116,  144,  145 
Precordial  bulging  in  pericarditis, 
153 

pulsation,  49 
Pulmonary  abscess,  139 

apoplexy,  138 

arterial  pulsation,  46 

artery,  aneurysm  of  the,  193 

cancer,  141 

capillary  pulse,  182 

hemorrhage,  137 

hyperaemia,  137 

gangrene,  140 

insufficiency,  181 

oedema,  137 

resonance  exaggerated,  65 

sounds  in  auscultation,  72 

stenosis,  183 

thrombosis,  138 

tuberculosis,  130 
Pulsation  of  the  epigastrium,  50 
Pulse,  capillary,  46 

collapsing,  174 

characteristics,  51-55 

dicrotic,  54 

in  asthma,  119 

broncho-pneumonia,  129 
lobar  pneumonia,  126 

radial,  51 

''water  hammer,"  174 
Pulsus  bigeminus,  54 

paradoxicus,  54 

trigeminus,  54 
Pyo-pericardium,  157 

Quincke's  pulse,  46 

Rales,  varieties  of  85 
in  asthma,  120 


INDEX. 


199 


Rales  in  broncho-pneumonia,  130 

in  lobar  pneumonia,  128 
Regions  of  the  chest,  1-8 
Resonance,  amphoric,  68 

cracked-pot,  70 

exaggerated  vesicular,  Qd 

tympanitic,  67 

vesicular,  64 

vocal,  80, 
Respiration  (see  Breathing),  39 
Respiratory  change  of  sound,  69 

expansion  in  emphysema,  121 

sounds,  72-78 
Rhachitic  chest,  36 

rosary,  36 
Rhonchal  fremitus,  59 
Ribs,  landmarks  of  the,  32 

Scapula,  landmarks  of  the,  32 
Shoemaker's  breast,  36 
Sibilant  rales,  86 
Size  of  the  chest,  34 
Sonorous  r^les,  86 
Sound,  bell,  89 

elements  of,  63 
Sounds,  auscultatory,  72 

cardiac,  89 

cough,  83 

friction,  88 

percussion,  63 

pleuritic,  144 

pulmonary,  72 

succussion,  89,  111 

tussive,  83 

vascular,  108 

venous,  110,  111 

whispering,  83 
Spinal  curvatures,  37 
Spleen,  landmarks  of  the*  31 
Sternal  lines,  23 


Stethoscopes,  70,  71 

Subclavian    artery,    sounds    over 

the,  100,  109 
Swellings  of  the  chest-wall,  113 

Tachycardia,  56 
Thrombosis  of  the  heart,  166 
Trachea,  27 
"  Tracheal  tone,"  67 

"tugging,"  190 
Tricuspid  insufficiency,  184 

stenosis,  186 

valve,  position  of,  29 
Tuberculosis,  acute  miliary,  131 
Tumors  of  the  chest-wall,  113 

heart,  166 
Tussive  or  cough  sounds,  83 
Tympany,  67 

Valleix's  points  of  tenderness, 

113 
Valves,  cardiac,  29 
Valvular  lesions,  173 

murmurs,  96 
Vascular  sounds,  108 
Venous  hum.  111 

in  aneurysm,  191 

pulsation,  45,  174 

sounds,  110 
Vertebrae,  landmarks  of  the,  31 
Vesicular  resonance,  64 

respiration,  73 
interrupted,  182 
Vesiculo-tympany  in  pleurisy,  108 
Vocal  fremitus,  60 

sounds,  80 

Whisper,  amphoric,  83 

cavernous,  83 
William's  tracheal  tone,  67,  69 
Wintrich's  change  of  sound,  69 


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S  fession  at  large,  as  indicated  by  advices  from  his  large  corps  of  canvassers.  <5 

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